Written by Rebecca V. Taylor, MD, MA, Assistant Professor , Division of Child and Adolescent Psychiatry
SIB and the Intersection of Race, Culture, and Ethnicity
When most of us think of self-injurious behavior, we think of those who intentionally cut themselves. The typical person who comes to mind as engaging in non-suicidal self-injury (NSSI) is a white middle class female teenager. It can be easy to fall into the trap of only asking patients who fit this mold about intentional self-harm. While it is possible there is some truth to this stereotype, it is also true that when we do not look for something, we will never see it. Our current approach and research focus may have thus far failed to appreciate the extent of NSSI in other cultures, races, and ethnicities. Our prejudices may influence how we interview and help our patients; we often are prone to not asking important questions around self-harm and NSSI based on skin tone, ethnicity, and country of origin. Identifying these tendencies is one way we can engage in patient care that does not fall prone to preexisting biases and stereotypes.
The reality is that many people, often adolescents, from a variety of backgrounds, ethnicities, and cultures engage in NSSI. There are lots of reasons why someone might turn to NSSI, and it can take many forms beyond cutting behaviors. For some, NSSI includes easily accessible acts, such as pinching oneself or pulling out their hair. For others, it can be more complicated and involve using sharps to cut oneself, or using fire to inflict burns. Reported motives vary, but frequently cited reasons include distraction from emotional pain, an attempt to punish oneself, poor impulse control without a clearly defined reason, seeking a caring connection from others, among many others. People may continue to engage in NSSI because it provides an outlet when other attempts at coping or distress tolerance fail. Whatever the reasons for starting or continuing, it is a phenomenon that cuts across racial and ethnic lines and does not always follow the stereotyped image of a white female teenager.
Research around NSSI is lacking in general, and more so when it comes to different cultures, identities, races, and ethnicities. The existing research shows that NSSI does in fact exist in other countries, as well as in minoritized populations in western culture. Traditional research done here, and even in what is quoted in the DSM, suggests that females are much more likely to engage in NSSI. However this does not appear to be accurate in other cultures, as many other cultures, such as in China and Turkey, report rates similar across genders. There is also a lack of research in to NSSI among those who identify as anything other than the traditional male female binary, which leaves us with very little knowledge of the intersection of NSSI with gender identity. The role of culture when it comes to NSSI is another factor that needs more research and examination. Understanding NSSI in the cultural context is imperative, as there are many cultures where it is seen as an accepted practice. Tattoos, for example are a form of self-injury, as anyone who has gotten a tattoo will tell you that it is quite painful. There are cultures all over the world, including here, where the application of tattoos is both accepted and even expected. Applying Caucasian centric, western understandings of NSSI in these situations runs the risk of pathologizing something that may even be culturally normal in a different context.
There has been significant time and research spent trying to understand NSSI in the western world, but that research does not translate to other cultures and countries. What this means practically is that NSSI needs to be assessed and understood at an individual level for every patient, and our bias towards what we think we know about NSSI needs to be challenged when we overlay the dimensions of race, ethnicity, culture, gender identity, and socioeconomic status.
Resources:
Khan, A., & Ungar, M. (2021, December 3). Resilience to Self-Harm: A Scoping Review of Protective Factors That Aid in Recovery Among Marginalized Young People. Crisis: The Journal of Crisis Intervention and Suicide Prevention. Advance online publication. http://dx.doi.org/10.1027/0227-5910/a000831
Gholamrezaei M, De Stefano J, Heath NL. Nonsuicidal self-injury across cultures and ethnic and racial minorities: A review. Int J Psychol. 2017 Aug;52(4):316-326. doi: 10.1002/ijop.12230. Epub 2015 Dec 8. PMID: 26644040.