Applied Psychology OPUS

Non-Suicidal Self-Injurious Behavior in Adolescents across Gender and Sexual Orientation

Rebecca Moser

Suicide is the third leading cause of death for youth between the age of 10 and 24, with approximately 4,600 young people dying by suicide each year (Centers for Disease Control [CDC], 2014). One of the greatest risk factors for suicide attempts in young people is a history of non-suicidal self-injurious behavior (CDC, 2014). The DSM-5 defines non-suicidal self-injury (NSSI) as 5 or more days of engaging in self-injurious behavior that is performed with the anticipation that the injury will result in some bodily harm, but lacks suicidal intent (5th ed.; DSM–5; American Psychiatric Association, 2013). NSSI in adolescents has been linked to a decrease in psychosocial functioning over time and is associated with numerous other negative long-term outcomes, such as high levels of overall body dissatisfaction, low self-esteem, frequent interpersonal problems, and higher rates of psychiatric disorders than in adolescents who do not engage in NSSI (Barrocas, Giletta, Hankin, Prinstein, & Abela, 2015; Claes et al., 2015; Tatnell, Kelada, Hasking, & Martin, 2014).

Prevalence rates of NSSI among adolescents ranges from 15-30% (Bakken & Gunter, 2012; Claes, Luyckx, & Bijttebier, 2014; Jacobson & Gould, 2007; Muehlenkamp, Williams, Gutierrez, & Claes, 2009; Swannell, Martin, Page, Hasking, & St John, 2014), and varies in manifestation across different demographic groups during adolescence, particularly gender and sexual orientation. Specifically, adolescent girls are more likely than adolescent boys to engage in NSSI. In addition, sexual minority youth (i.e., LGBT youth) engage in higher rates of NSSI than heterosexual teens and are at a greater risk for suicidality. This literature review, therefore, examined how NSSI in adolescents manifests across gender and sexual orientations.

Differences in NSSI Behaviors across Gender

Girls are more likely to engage in NSSI and have a higher probability for their NSSI behaviors to become chronic than boys (Barrocas et al., 2015; Muehlenkamp et al., 2009). Over time, females tend to show little decline in NSSI, while NSSI among males tends to taper off slowly throughout adolescence (Muehlenkamp et al., 2009).  Yet, research also suggests that boys are less likely to report NSSI behaviors to parents, teachers, or friends as compared to girls, which may contribute to the gender difference in prevalence rates (Baetens et al., 2014). Nevertheless, when NSSI is reported, there is a noticeable difference in the methods of NSSI employed by boys and girls.

NSSI, which includes an array of behaviors that are done to intentionally cause pain to oneself, is expressed differently in boys and girls throughout adolescence (Muehlenkamp et al., 2009). While most stereotypes indicate that cutting or slashing are the most common type of NSSI, this is only true for adolescent girls (Baetens et al., 2014; Claes et al., 2015; Swannell et al., 2014). For adolescent boys, self-battery (i.e., hitting or burning oneself) is the most frequent method of NSSI (Baetens et al., 2014; Claes et al., 2015). Thus, engaging in NSSI during adolescence typically presents differently by gender in terms of frequency, chronicity, and method. (Barrocas et al., 2015; Baetens et al., 2014; Claes et al., 2015; Muehlenkamp et al., 2009; Swannell et al., 2014) This notion about NSSI behaviors differing within demographic constructs also holds true for adolescents who identify as LGBT.

NSSI Behaviors across Sexual Orientations

Lesbian, gay, bisexual, and transgender (LGBT) adolescents engage in higher levels of NSSI overall as compared to their heterosexual peers (Bakken & Gunter, 2012; Reisner, Biello, Perry, Gamarel, & Mimiaga, 2014). Out of the LGBT community, bisexual and transgender adolescents are the most likely to engage in NSSI (Bakken & Gunter, 2012). In terms of transgender youth, trans men engaged in NSSI significantly more than trans women (Claes et al., 2015). It is unknown why LGBT youth engage in NSSI more frequently than heterosexual youth; however, there are some theories as to why this gap exists.

Adolescence is already a time of great confusion, and struggling with sexual identity on top of other pubertal issues may lead to the use of NSSI as a coping strategy (Bakken & Gunter, 2012; Claes et al., 2014). If the path to sexual identity is egodystonic (dissonant) with one’s sense of self, then NSSI could be utilized as a form of self-punishment or as an emotional release from feelings of confusion or even self-hate (Claes et al., 2015). In addition, adolescents who experience bullying are more likely to self-injure. This is particularly true for LGBT youth who experience victimization from their peers as a result of their sexuality (Bakken & Gunter, 2012; Liu & Mustanski, 2012). NSSI may also be used as a coping mechanism to suppress or avoid suicidal ideation by LGBT youth (Claes et al., 2015). Although LGBT adolescents are more likely than their heterosexual peers to engage in NSSI, there is variability in the frequency of NSSI behaviors depending on the sexual orientation one identifies with (Bakken & Gunter, 2012; Claes et al., 2015; Reisner et al., 2014).

Conclusion

NSSI presents itself differently across genders and sexual minorities in terms of frequency, chronicity, method, and function (Barrocas et al., 2015; Baetens et al., 2014; Bakken & Gunter, 2012; Claes et al., 2015; Muehlenkamp et al., 2009; Reisner et al., 2014; Swannell et al., 2014). Girls are more likely to have chronic NSSI and use techniques such as cutting or slashing (Barrocas et al., 2015; Muehlenkamp et al., 2009; Swannell et al., 2014). LGBT youth, particularly bisexual and transgender teens, are more likely to self-injure than heterosexual youth (Bakken & Gunter, 2012; Claes et al., 2014; Claes et al., 2015; Reisner et al., 2014). The increased risk of NSSI in LGBT youth may be due to the added stress and confusion of grappling with one’s sexual identity.

There are several major limitations to the research on NSSI in adolescents. Few studies have examined the effects of NSSI on sexual minority youth and the existing literature does not fully describe why some adolescents do or do not engage in NSSI, even when presented with similar risk factors, such as sexuality or gender. In addition, existing studies do not operationalize NSSI consistently. For instance, not all studies follow DSM criteria when defining NSSI within their study, while other studies do not distinguish between non-suicidal self-injury from self-injury with suicidal intent; thus, drawing conclusions from comparisons across studies should be done with caution.

Despite these limitations, the recent expansion of research on NSSI has allowed for increased dialogue about the topic, especially in regards to its connection to future suicidality. With more research than ever being conducted about NSSI, psychologists are more equipped to help patients struggling with it and more effective treatments can begin to be tested, which will allow psychologists to tailor treatments based on an individual’s gender and sexuality in an effort to produce the greatest results. NSSI can no longer be ignored, and researchers should continue to study the phenomenon, in order for the psychological community to become more knowledgeable about how to combat these behaviors.

References

American Psychiatric Association. (2013). Non-suicidal self-injury. In Diagnostic and statistical manual of mental disorders. (5th ed.). Arlington, VA.: American Psychiatric Publishing.

Baetens, I., Claes, L., Onghena, P., Grietens, H., Van Leeuwen, & K., Pieters, C. (2014). Non-suicidal self-injury in adolescence: A longitudinal study of the relationship between NSSI, psychological distress and perceived parenting. Journal of Adolescence, 37(6), 817-826.

Bakken, N. W., & Gunter, W. D. (2012). Self-cutting and suicidal ideation among adolescents: Gender differences in the causes and correlates of self-injury. Deviant Behavior, 33(5), 339-356.

Barrocas, A. L., Giletta, M., Hankin, B. L., Prinstein, M. J., & Abela, J. R. Z. (2015). Nonsuicidal self-injury in adolescence: Longitudinal course, trajectories, and intrapersonal predictors. Journal of Abnormal Child Psychology, 43(2), 369-380.

Claes, L., Bouman, W. P., Witcomb, G., Thurston, M., Fernandez-Aranda, F., & Arcelus, J. (2015). Non-suicidal self-injury in trans people: Associations with psychological symptoms, victimization, interpersonal functioning, and perceived social support. Journal of Sexual Medicine, 12(1), 168-179.

Claes, L., Luyckx, K., & Bijttebier, P. (2014). Non-suicidal self-injury in adolescents: Prevalence and associations with identity formation above and beyond depression. Personality and Individual Differences, 61-62, 101-104.

Jacobson, C. M., & Gould, M. (2007). The epidemiology and phenomenology of non-suicidal self-injurious behavior among adolescents: A critical review of the literature. Archives of Suicide Research, 11(2), 129-147.

Liu, R. T., & Mustanski, B. (2012). Suicidal ideation and self-harm in lesbian, gay, bisexual, and transgender youth. American Journal of Preventive Medicine, 42(3), 221-228.

Muehlenkamp, J. J., Williams, K. L., Gutierrez, P. M., & Claes, L. (2009). Rates of non-suicidal self-injury in high school students across five years. Archives of Suicide Research, 13(4), 317-329.

Reisner, S. L., Biello, K., Perry, N. S., Gamarel, K. E., & Mimiaga, M. J. (2014). A compensatory model of risk and resilience applied to adolescent sexual orientation disparities in nonsuicidal self-injury and suicide attempts. American Journal of Orthopsychiatry, 84(5), 545-556.

Suicide Prevention. (2014, January 09). Retrieved April 6, 2015, from http://www.cdc.gov/violenceprevention/pub/youth_suicide.html

Swannell, S. V., Martin, G. E., Page, A., Hasking, P., & St John, N. J. (2014). Prevalence of nonsuicidal self-injury in nonclinical samples: Systematic review, meta-analysis and meta-regression. Suicide and Life-Threatening Behavior, 44(3), 273-303.

Tatnell, R., Kelada, L., Hasking, P., & Martin, G. (2014). Longitudinal analysis of adolescent NSSI: The role of intrapersonal and interpersonal factors. Journal of Abnormal Child Psychology, 42(6), 885-896.