Originally posted March 2019 by Amy Chandler
Measuring and recording self-harm and suicide is challenging, and yet many claims about suicide and self-harm are fundamentally reliant on an attempt to do so. However, concerns have been raised about the nature of statistical knowledge about self-harm and suicide for some time, especially where this relates to ‘official records’ (Atkinson 1978). For instance, researchers continue to acknowledge that official rates of suicide may be affected by the stigma that remains attached to suicide, particularly in some groups (e.g. children) or religious communities (Scowcroft 2017). This may mean that those charged with recording the nature of a death may be more likely to list the cause as ‘accidental’ rather than ‘suicide’.
Studying how suicide is determined
Sociologist Stefan Timmermans investigated how cases of possible suicide are decided through an ethnographic study of the professional lives and practices of medical examiners in the United States. He writes:
“the statistical suicide rate constructed by sociological and public health criteria is far removed from either the smell of death or the memories of the living” (2006 p. 107).
As a sociologist interested in how death, suicide, and self-harm are socially shaped and given meaning, this is an important reminder to maintain some focus on the ‘lived’ (and dead) body: how ‘facts’ such as suicide rates and decisions about motive or cause of death must often be gleaned from bodies, and the interaction between bodies – alive and dead.
In his study, Timmermans proposed that suicides could be understood in (at least) three ways:
biographical suicides – suicide as understood by families, in the context of the deceased person’s life – such deaths may not be recorded as suicides, but are nevertheless understood by families as such;
statistical suicide rates – which focus on objectivity and the attempted identification of the ‘true’ suicide rate – these may include undetermined deaths that may have been suicide;
medico-legal suicide – the ‘opinion’ of the medical examiner as to the likelihood of the death being caused by suicide.
These different ways of understanding suicide coexist, unsettling the idea that suicide is ‘one thing’, and that a suicide rate can ever reflect what suicide ‘really is’. Rather, Timmermans argued, suicide can mean different things to these different groups, who can have competing views. I would add a further layer and suggest that suicide may have meant something else again to the deceased (or in ‘near miss’ self-harm, the almost deceased). Motivations may fluctuate, and ascribing motivation – even where the person involved can be asked directly – is a notoriously tricky business (Arensman & Keeley, 2012).
If measuring suicide seems perilous, measuring self-harm is perhaps even more difficult. Self-harm has, historically and recently, had many different names – self-injury, self-mutilation, deliberate self-harm, non-suicidal self-injury, wrist cutting syndrome, and more (Chandler et al., 2011, Chaney 2017). Further, the term ‘self-harm’ (or something like it) can refer to a very wide range of different practices: cutting the skin, overdosing on prescribed medication, ingesting poisons, such as pesticides or cleaning chemicals, burning, inserting objects, breaking bones. Some definitions or understandings of what self-harm is might also include drug and alcohol use, risky sex, negative thinking about the self, or bullying the self online – known as ‘cyber self-harm‘.
The connection between the term used, and the practices it refers to, is not consistent. For instance in UK health policy and research, ‘self-harm’ tends to refer to ‘self-injury or self-poisoning, irrespective of the apparent purpose of the act’ (as defined in national clinical guidelines). In contrast, some US based literature has used the same term to refer to self-injury alone. Elsewhere, the proposed psychiatric classification of ‘non-suicidal self-injury’ is used – though this excludes self-poisoning (unlike the UK policy definition). All of this means that caution should be exercised when interpreting statistical knowledge about self-harm.
Leading from this definitional inconsistency, studies which report on ‘self-harm’ are not always looking at the same acts. As well as disciplinary and national variations in terms used, the types of self-harm addressed in research also varies across different clinical and community settings.
Many studies examine cases of self-harm admitted to or presented at Accident and Emergency departments (70-80% of whom will have taken an overdose of prescription medication) (Geulayov et al., 2016). Other, community-based studies using surveys may invite people (often school or university populations) to respond to questions such as ‘have you ever hurt yourself on purpose’ (Mars et al., 2014; O׳Connor et al., 2014). Some even combine questions about self-harm with a question about suicidal thoughts, and a recent NIHR study has raised concerns about the variability and imprecision of measures for self-harm used in surveys. Among young people who tick ‘yes’ in surveys, around 60-70% will report self-cutting, if asked about methods used (often they are not). In contrast, particularly in the US, researchers might use the proposed diagnostic criteria for ‘non-suicidal self-injury’ (featured in the DSM-5, diagnostic manual for the American Psychiatric Association) – criteria which excludesself-harm via overdoses and refers to a rather messy assortment of injuries largely to the ‘outside’ of the body (Chandler 2016).
Aside from the confusing array of different practices studied as ‘self-harm’ by researchers working in very different settings, and sometimes with quite different population groups, these studies also tend to result in rather different pictures of self-harm in terms of gender.
Studies which use surveys with groups of young people tend to find that many more women than men report self-harm. A 2017 study in the UK found that 32% of young women reported ever self-harming, compared to 11% of young men. This study, and others, have suggested that there is a current rise in young people (especially young women) reporting self-harm. However, the extent of this apparent rise varies. A report published in 2018 indicated a very small rise in the number of young women reporting harming themselves, but the survey report does not suggest what forms of self-harm participants were referring to (self-harm and suicide attempts were combined); and the numbers reporting were far lower than the 2017 report: 7.3% of girls and 3.6% of boys aged 11-16.
A study of General Practitioner (GP) records also reported an increased number of young women self-harming (Carr et al 2016). These studies raise some interesting questions though – for instance, are we seeing an increased number of young women self-harming, or an increased number of young women seeing their general practitioner about self-harm? Or even, an increased likelihood that GPs will record self-harm on female patients records? The same study found that 70% of cases recorded in the GP records were overdoses, but we know from community surveys that young people are far more likely to report self-injuring (via cutting, burning or hitting) and also very unlikely to report seeking professional medical care for this. It is possible that self-harm that is treated in hospital (often an overdose) may be more likely to also end up being recorded in GP records. As such, while the study does provide another useful perspective on potential rates of self-harm – it is still likely to be only part of the picture.
What people say, what people do, and what gets recorded
Self-harm and suicide are both hugely complex and difficult to measure. What people say may be different from what they do, which may be different again from what gets recorded. Measuring is important – it can point to inequalities in rates, which might help us to better understand the practices, or ask better questions at least. Care needs to be taken, though, when it comes to interpreting statistical knowledge about self-harm and suicide. Statistics about these practices are always partial, and researchers and practitioners know this. Statistics can also be very appealing in their simplicity; but this is dangerous, and towing simplistic lines of argument will lead to acts like self-harm and suicide being misunderstood, misconstrued. This is why it is vital that statistical knowledge is enhanced, complemented and tested by qualitative, interpretive knowledge as well.
American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Arlington, VA: American Psychiatric Association.
Arensman, E., & Keeley, H. (2012). Defining intent. Psychiatry Professional, Spring 2012, 8-9.
Atkinson, J.M. (1978). Discovering Suicide: Studies in the Social Organization of Sudden Death. London: Macmillan Press.
Carr, M.J., Ashcroft, D.M., Kontopantelis, E., Awenat, Y., Cooper, J., Chew-Graham, C., et al. (2016). The epidemiology of self-harm in a UK-wide primary care patient cohort, 2001–2013. BMC Psychiatry, 16, 53.
Chandler, A. (2016). Self-injury, medicine and society: authentic bodies. Basingstoke: Palgrave Macmillan.
Chandler, A., Myers, F., & Platt, S. (2011). The construction of self-injury in the clinical literature: a sociological exploration. Suicide and Life Threatening Behavior, 41, 98-109.
Chaney, S. (2017). Psyche the Skin: A History of Self-Harm. London: Reaktion Books.
Geulayov, G., Kapur, N., Turnbull, P., Clements, C., Waters, K., Ness, J., et al. (2016). Epidemiology and trends in non-fatal self-harm in three centres in England, 2000–2012: findings from the Multicentre Study of Self-harm in England. BMJ Open, 6.
Mars, B., Heron, J., Crane, C., Hawton, K., Kidger, J., & Lewis, G. (2014). Differences in risk factors for self-harm with and without suicidal intent: Findings from the ALSPAC cohort. J Affective Disorders, 168.
O׳Connor, R.C., Rasmussen, S., & Hawton, K. (2014). Adolescent self-harm: A school-based study in Northern Ireland. Journal of Affective Disorders, 159, 46-52.
Scowcroft, E. (2017). Suicide statistics report 2017. London: Samaritans.
Timmermans, S. (2006) Postmortem: How Medical Examiners Explain Suspicious Deaths. Chicago, University of Chicago Press
(Image by arielrobin via pixabay https://pixabay.com/photos/measure-yardstick-tape-ruler-1509707/)