Self-Inury Through History and in Many Cultures

    Self-injury and multilation have been prevalent throughout history and in many cultures today.  Self-injury in a cultural sense includes both acts of injury towards oneself and willingly allowing others to inflict pain or injury.  In many cases, self-injury is related to religious beliefs and practices.  The practice of self-injury may be so prevalent because it is part of many creation myths.  For example, in the Indian myth Rigveda, the gods tie up Purusa, sacrafice him, and divide his body into portions (Favazza, 1996).  Each part of his body becomes a different part of the world.  His eyes become the sun, his mind the moon, and his head becomes the sky.  His feet become the earth.  Creation myths full of bodily destruction are not only prevalent in Eastern cultures.  In a Scandinavian myth about Prose Edda, it is believed that a cow and a giant, Ymir, were both mutilated by the gods to create the world.  In this myth, Ymir's blood became the sea and lakes, his flesh became the earth, his bones became the mountains, and his teeth and jaws become rocks, and his skull became the sky (Favazza, 1996).
    The myth of mutilation may be what leads many cultures to engage in rituals that seem barbaric according to Western standards.  In some cultures, enduring painful rituals are a way to prove that one is worthy of a certain position in society.  In many cultures such as that of Siberia and Australian Aborigines, it is believed that for one to be become a Shaman they have to endure rituals that include torutre and dismemberment, reduction of the body to the skeleton by scraping away of the flesh, and a renewal of blood.  It is believed that these rituals will allow one to spend time in hell and the ascend to Heaven after which they will be able to heal others (Favazza, 1996).
    Enduring pain and mutilation to gain a position in religion is not common in Western religions today, but it has been common in Christianity throughout history.  Many of the people viewed as martyrs and saints to do gained their status by enduring some type of painful mutilation.  The very basis of Christianity is a belief that Jesus Christ allowed himself to be nailed to a cross in order to save people from their sins (Favazza, 1996).  The idea that slef-injury can be a form of repentance may stem from this.  The idea that pain must be endured in order to prove one's faith can be seen in the story of Saint Potitus.  Potitus was stretched on a rack when he refused to denounce his religion and for enduring this pain, he gained the status of a saint (Favazza, 1996).
    Examples of actual rituals involve self-injury can be found in many cultures to this day.  In Papua New Guinea, it is common for men to injure their noses.  Nasal mutilation is practiced in initiation rituals of male adolescents.  In the coming of age ritual in the Gahuka-Gana tribe in Papua New Guinea, boys are covered with clay by their mothers before they are sent off to a river where warriors wait for them.  At the river, they insert sticks and leaves up their noses to induce hemorraging.  Boys spend six weeks living with warriors, repeating the ritual until their initiation into manhood is complete (Hogbin, 1970).  The reason for inducing nasal hemorraging in these tribes is that it is a way for a boy to cleanse himself and is related to female menstruation.
    Finger mutilation is common in many tribes in Africa.  In one tribe, the Dugum Dani in New Guinea young girls cut their fingers off as a sacrifice at funerals.  In another tribe, the Bushman of Africa, it is believed that sickness can be cured by removing parts of the fingers.  In this tribe, part of a finger is removed for every sickness that someone gets, started with the little finger  (Favazza, 1996).  The Hottentot tribe removed parts of the fingers as a sign of engagement or marriage.  It was believed that in order to remarry, a widow had to remove a finger to break the bond between herself and her dead husband.  In the Pacific Islands, finger amputation is common as a sign of mourning after the death of a close relative.
    May other forms of culturally sanctioned self-injury exist and rituals include injury of almost every body part.  Self-injurious behavior has been recognized by many fields of study including anthropology, suicidology, criminology, psychiatry, biology, and psychology to name a few (McKay & Ross, 1979).  The many terms used to refer to self-injurious behavior include such terms as self-aggressive behavior, parasuicide, symbolic wounding, self-mutilation, self-destructive behavior, and deliberate self-harm among other terms(McKay & Ross, 1979).  Terms used to discuss self-injurious behavior bring with them different connotations of  what the behavior means or entails.  For instance parasuicide makes one think that the self-injurious behavior is related to some suicide intent when in fact many researchers believe that self-injurious behavior does not correlate with suicidal behavior.  The many fields that study self-injurious behavior also have different takes on what the behavior can mean.  These issues make the study and definition of self-injurious behavior difficult and are part of the reason why research on the problem of self-injurious behavior has not been prevalent until recently.
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Defining Self-Injurious Behavior

    In a review by Favazza (1998), he found that self-injurious behavior has been described throughout history and that it is found in many cultures around the world.  In many cultures, self-injurious behavior is used in many religious rituals and most commonly in coming of age rituals (Favazza, 1998).  In the Hindu culture, people pierce themselves to make themselves more appealing to the God Murugon.  In the Aztec culture, they anointed sacred idols with blood from their penises as a sign of devotion.  The type of self-injurious behavior that is culturally sanctioned is not viewed as a form of deviant self-injurious behavior.
    The cases of self-injurious behavior that will be discussed here are all viewed as a deviant form of self-injurious behavior, although the definition differs among researchers.  Research on deviant self-injurious behavior began in the late 1960’s and focused on wrist cutting behavior.  In a study by Graff and Mallin (1967) the typical wrist cutter was portrayed as “an attractive, intelligent, unmarried young woman, who is either promiscuous or overtly afraid of sex, easily addicted and unable to relate to others…”  Early studies on self-injurious behavior were faulted as they focused only on one type of behavior, wrist cutting, which they linked to suicide.  They excluded individuals who injured themselves in different ways (Favazza, 1998).
    It was not until Kahan and Pattison (1983) put together a prototype model for deliberate self-harm syndrome that they derived from 56 published reports that self-injurious behavior was taken to be a disorder that was separate from suicide.  Their syndrome was described as multiple episodes of low lethality self-injurious acts such as cutting and burning.  The acts were characterized by a sense of relief and there was no conscious suicidal intent in self-injurers.  The behavior usually endured for several years.  The distinction between self-injury and suicide is made by more recent researchers who believe that the behavior is an attempt to feel better whereas suicide is an attempt to end all feeling (Favazza, 1987; Tantam & Whitaker, 1992; Rosen & Walsh, 1988).
    Deviant self-injury is broken into three main types of before.  The first is major self-injury.  It consists of infrequent acts in which a great deal of tissue is destroyed, usually by castration or amputation.  This type of behavior is associated with psychotic or intoxicated states.  Stereotypic self-injury consists of fixed, often rhythmic patterns such as head banging, eyeball pressing, and finger or arm biting.  It is most commonly associated with autism and mental retardation.  Superficial or moderate self-injury is the most common form of self-injury.  It is usually a significant indicator of emotional stress and usually is of low lethality.  It is usually sporadic and repetitive.  It seems to have an addictive quality and is most common in the form of skin cutting or burning.  The research that will be reviewed here is based on superficial self-injury.
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Research on the Causes of Deviant Self-Injurious Behavior

    Once researchers had some sense of a definition of self-injurious behavior, the next step was to try to understand what causes the behavior.  Much of the research has shown that there is a correlation between self-injurious behavior and childhood events.  The belief is that self-injurious behavior occurs in people who endure stressful situations in childhood such as physical or sexual abuse, neglect by parents, loss of a parent in childhood due to death or divorce and other stressful situations.  Other researchers believe that self-injurious behavior may be learned by children who endure physical types of abuse because of the chemical released in their bodies during abuse.  Still other researchers think of self-injurious behavior as a symptom of other disorders such as personality disorders or bipolar disorder (Favazza, 1996).
     In a study of childhood origins of self-injurious behavior, Herman, Perry, and van der Kolk (1991), studied  seventy-four subjects with personality disorders or bipolar II disorder over an average of four years.  Subjects were monitored for suicide attempts, self-injurious behavior and eating disorders.  A self-report of childhood trauma, disruptions of parental care, and dissociative phenomena were obtained.  Dissociative phenomena are defined as feelings of numbness, feeling “dead” or “unreal”.  Childhood trauma and disruption of parental care were obtained with the Traumatic Antecedent Questionnaire.
     Self-destructive behavior was broken into seven categories, including suicide attempts, cutting, other self-injurious behavior such as head banging, picking or burning, suicide attempts plus self-injurious behavior, binge eating, anorexia, and risk taking.  Correlations were run on the type of behavior and type of disorder, type of trauma experienced in childhood and dissociation.  Of the disorders that the subjects were diagnosed with, borderline personality pathology was the only one related to suicide attempts, cutting, and other self-injurious behavior (Hermann et al, 1991).  Childhood trauma scores were related to suicide attempts, cutting, other self-injurious behavior, and anorexia.  Sexual abuse was most strongly related to all forms of self-destructive behavior.  Witnessing domestic violence was highly correlated to suicide attempts.  Dissociation scores were correlated with cutting behavior and anorexia.  An important finding in this study also showed that subjects who reported histories of sexual abuse and those with severe histories of neglect and separation were the most likely to continue self-destructive behavior during the follow-up phase of the study even if they were in therapy (Hermann et al, 1991).
     A study by Anderson, Herbison, Martin, Mullen, Phil and Romans (1995) focused on the relationship of sexual abuse in childhood and deliberate self-injury.  Their study was based on the conclusions found from such studies as those by Herman et al (1991).  In their study, they focused on community samples rather than samples of individuals diagnosed with disorders.  They selected a random sample of women who had reported having been sexually abused as children and a similar group that did nor report abuse (Anderson et al, 1995).  Women who were originally selected for the control group who later reported incidents of sexual abuse in childhood were included in the experimental group.  Of the women interviewed, only 23 (4.8% of the entire study population) reported a history of deliberate self-injury.  Of these 23 women, 22 reported sexual abuse in childhood.  91% of the women who were interviewed who had histories of sexual abuse in childhood did not engage in deliberate self-injury.  The individuals who did engage in self-injurious behavior differed from other subjects in that they tended to have other negative childhood influences including physical abuse by a parent, neglect by parents, and loss of a parent to separation or divorce.  The findings by Anderson et al. suggest that although sexual abuse seems to be a factor involved in self-injurious behavior, it is not a predictor of that behavior (1995).  The findings suggest that a combination of stressful childhood experiences lead to these types of behavior.
     Another approach to understanding causes of self-injurious behavior are based on a biological model.  Most of the research on episodic and repetitive self-injury has focused on chemical levels in subjects.   In one study, Coccaro, Klar, and Siever (1989) tried to show a relation between serotonergic system functions in the brain and self-injurious behavior.  They found a relationship between low serotonin and increased impulsive aggression against others and oneself.  The findings failed to show why some individuals showed aggressive behavior towards others and some show aggressive behavior toward themselves (Coccaro et al, 1989).
    A more reasonable chemical explanation of self-injurious behavior is given by Russ (1992).  It was found that there were increased levels of enkephalins in the blood plasma of habitual cutters.  These self-cutters stated that the cutting was painless and that they performed the act in order to provide temporary relief from dissociation.  Russ believed that the behavior may be related to an addiction to enkephalins.  He explained that an individual may become addicted to enkephalins in the same way that one becomes addicted to other opiates such as heroin.  As the levels of enkephalins lower in the body of a self-cutter, they have to repeat the behavior to avoid withdrawal symptoms. Although Russ's theory explains why many self-cutters may continue the behavior, it fails to explain what triggers the behavior.
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The Link To Suicide
    Studies using biological models are helpful in trying to understand the chemical components of why self-injurers continue behavior, but they do fail to acknowledge the psychological aspects of self-injury and they tend to link the behavior to suicidal tendencies.  Many researchers have suggested that self-injurious behavior should not be referred to as attempts of suicide.  Some researchers suggest that the behavior is actually an alternative to suicidal behavior.  Farrand and Solomon (1996) believe that it is imperative to separate self-injury from a definition of suicide if researchers truly want to understand the behavior.
    Farrand and Solomon criticize such individuals as Fredman, Lucey, and Reder (1991) who assume that all self-injury is an attempt to show others that a crisis is beyond an individual's control and that individuals are on the way to suicidal tendencies (1996).  Farrand and Solomon believe that the behavior is often not used to communicate with others, especially since many people who engage in self-cutting or self-burning behavior do so in private and hide the injuries from others.  They suggest that the behavior is more a way for an individual to gain control for themselves.  They interviewed four young women who engaged in self injurious behavior to show that the behavior is not related to suicidal intent.
    The first girl interviewed, Helen, began self-injuring at 11 and continued until the time of the interview ten years later.  She explains her self-injuring as a form of coping, a way of transforming emotional problems into more manageable physical pain.  Helen emphasized the fact that she chooses to self-injure as a way to keep herself from feeling the need to commit suicide.  Another girl, Sue, explains that she uses self-injury as a way to deal with anger.  She says that when she is angry and cuts herself, it immediately calms her down.  Carol also uses self-injury as a way to deal with anger.  She believes that her anger is a result of sexual abuse by her father while she was growing up.  Carol, unlike the other girls described does have suicidal tendencies along with her tendency to self-injury.  She does make a distinction between the state of mind she is in when she self-injures and the state of mind that she is in when she tries to commit suicide.  Liz, the last girl interviewed, uses cutting herself as an alternative to being depressed.  She says that it helps her deal with stress.  Liz makes a distinction between suicide and self-injury, the same way that Carol does, although she does say that it becomes hard to explain that to other people.  Liz said that her attempts at suicide included overdosing rather than cutting, her form of self-injury.  She explains that even if her self-cutting is not an attempt to commit suicide, if other people asked her if she was trying to kill herself she would probably say yes.  She explains that the self-injury and suicide intent become blurred in her mind because of other people's perceptions of her behavior.  Liz's sentiment make it clear that a distinction between self-injury and suicide is hard to make but that it is imperative to understanding the two different behaviors (Farrand & Solomon, 1996).
      Although Farrand and Solomon's study was based on interviews with girls known to self-injury, the types of answers given by the girls for why they self-injure are similar to the answers given by women in another study. Williams and Wilkins (1994) looked at patients suffering from bipolar disorder and personality disorders.  In their study, they looked at methods of self-injury, privacy vs. exhibitionism, impulsivity vs. premeditation, and pain vs. analgesia for pain.  They also provided a question for participants about the main reasons that they self-injure.  Wilkins and Williams found that cutting/scratching (80%) was by far the most common type of self-injury.  They also found that 51% of their participants reported feeling no pain when self-injuring as opposed to 29% who reported feeling pain often.  Participants reported the behavior being more impulsive (51%) than premeditated(29%).
     The most important findings by William and Wilkins relate to the reasons that patients gave for self-injury.  The number one response (59%) for why they self-injured was "to feel concrete pain when the other pain I am feeling is so overwhelming and confusing that I can't grasp it"  (Williams and Wilkins, 1994).  The second highest answer (49%) for why they self-injured was to punish themselves for being "bad" or feeling angry.  One other reason that was given by many participants (39%) was that they used self-injury to reduce anxiety and despair that they felt they could not otherwise control (Williams & Wilkins, 1994).  None of the participants said that they self-injured as an attempt to commit suicide and only 7% of the participants said that the self-injury helped to keep them from acting on suicidal feelings, suggesting that there is a difference between suicidal behavior and self-injurious behavior.  Overall, it seems that the main reasons that people self-injury is due to a need to control emotion that they feel they can not otherwise control.
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Gender and Self-Injury
     Among researchers on superficial self-injury, there seems to be a consensus that more females engage in this type of behavior than males (Conterio & Favazza, 1986; Farrand & Solomon, 1996; Favazza, 1998).  In their 1986 survey, Conterio and Favazza found that 97% of respondents were female, and they compiled a "portrait" of the typical self-injurer, similar to the portrait put together by Graff and Mallin (1967).  They believed the typical self-injurer to be female, in her mid-20s to early 30s, engaging in the behavior since her early teens.  They believed she would be from middle- or upper-middle-class families, intelligent, well-educated, and from a background of physical and/or sexual abuse or from a home with at least one alcoholic parent. Eating disorders were often reported.  In Favazza's latest review of research on self-injury, he maintains the same portrait of the typical self-injurer (1998).  It seems that in thirty years not much has changed in terms of the type of people who self-injure.
     Research on why women engage in self-injurious behavior more often than men is not very common although the reasons for it have been speculated by many researchers.  Several thoughts on why women tend to self-injury more often than men do revolve around aggression and gender socialization.  Miller believes that women are socialized to internalize anger and men are taught to externalize it (1994).  This explanation is based on the belief that it is more acceptable for a women to hurt herself than to express anger towards others.  It may also be that men are taught to repress emotions so they may be able to keep emotions inside without them becoming overwhelming.  Men may also have more opportunity to express anger they might feel towards themselves in violent acts that are not related back to their feelings.  For instance, if a man is upset with himself or depressed, he may pick a fight with another person without realizing that the aggression stems from his personal feelings (Miller, 1994).
Miller's explanation seems to be acceptable given the reasons that many women in the studies reviewed here gave for why they self-injure.  Farrand and Solomon found in their interviews of girls that self-injury is often a reaction to feelings of anger (1996).  In Williams and Wilkins study, they found that a high percentage of women self-injure because they think they have been "bad" for feeling angry (1994).  It seems that the way that women are socialized not to be outwardly aggressive may have an effect on their aggressive behavior towards themselves.
     In the past thirty years since deviant self-injurious behavior became of interest to researchers, much has been learned about the type of people who are at risk for this type of behavior.  Psychological studies have shown that traumatic events in childhood, especially sexual abuse, are related to self-injurious behavior later in life.  Biologists have tried to explain how chemical differences in people who self-injure may lead to the behavior.  Despite all the studies that have been done, superficial self-injurious behavior is still highly misunderstood.  The one point that most researchers seem to agree on is that self-injurious behavior is separate from suicidal behavior and should be treated as such.
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The Modern Primitive Movement 

    In the discussion of self-injurious behavior, the focus has been on cultural practices in primitive socities and the form of self-injurious behavior that has been viewed as deviant.  It is important to note the trend of self-injury that has become accepted in Western societies including tattooing, body piercing, scarification and branding.  The movement of the modern primitive is a fairly recent phenomena, gaining power in the late 1980's.  Many forms of body modification have become mainstream in Western Society (Favazza, 1996), especially body piercing.  The term modern primitivism was coined by Fakir Musafar who is an adamant endorser of body piercing, skin stretching, and other such pratices.  Musafar publishes a magazine based on his ideas of body modification called "Body Play".  The interest in body modification can also be seen in the many web pages devoted to it.  For more information on body modification, please see some of the following links.

Body Modification Information
Body Play by Fakir Musafar
Urban Primitive Body Design
Body Modification Ezine
The Association of Professional Piercers
 

Self-Harm Information
Selfharm.com
Self_Injury, Secret Shame
 

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References
     Anderson, J., Herbison, G, Martin, J., Mullen, P., Phil, M., & Romans, S. (1995). Sexual abuse in childhood and deliberate self-harm. American Journal of Psychiatry, 152, 1336-1342.
     Coccaro, E., Klar, H., & Siever, L. (1989). Serotonergic studies in patients with affective and personality disorders: Correlates with suicidal and impulsive aggressive behavior. Archives of  General Psychiatry, 46, 587-599.
     Conterio, K. & Favazza, A. (1989). Female habitual self-mutilators. Acta Psychiatrica Scandinavica, 79, 282-289.
    Farrand, J. & Solomon, Y. (1996). Why don't you do it properly? Young women who self-injure. Journal of Adolescence, 19, 111-119.
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    McKay, H. & Ross, R. (1979). Self-Mutilation. Toronto: Lexington Books.
    Miller, D. (1994). Women Who Hurt Themselves: A Book of Hope and Understanding. New York: BasicBooks.
     Rosen, P. & Walsh, B. (1988). Self-Mutilation: Theory, Research, and Treatment. New York: Guildford.
     Russ, M. (1992). Self-injurious behavior in patients with borderline personality disorder: Biological perspectives. Journal of Personality Disorders, 6, 64-81.
    Tantam, D. & Whitaker, J. (1992). Personality disorder and self-wounding. British Journal of Psychiatry, 161, 451-464.
    Williams & Wilkins. (1994). Phenomenology of self-injury among inpatient women with borderline personality disorder. The Journal of Nervous and Mental Disease, 182, 524-526.
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