Using secondary analyses of data from a sample of 265 sexual minority youths, the authors examined correlates of cutting behavior to determine whether patterns are similar to those found in studies of self-injury with community samples of predominately heterosexual youths.
The sample consisted of youths who received services at an urban social service agency serving the sexual minority community; youths from the region attending social events, who located the survey through the Internet, or who were referred from other youth-serving agencies; and youths from out of state who found the survey through the Internet or were referred by youth-serving agencies. Prevalence of cutting was higher than that found in community-based samples of similar age groups. However, similar patterns of risk were found with regard to peer victimization, homelessness, suicidality, and depression. Female and transgender respondents were more likely to have engaged in cutting behavior than were male respondents. No significant race-based differences emerged. Both age and having knowledge of a supportive adult were associated with decreased likelihood of cutting. Additional findings link higher levels of "outness," higher occurrence of suicidality among social network, and higher rates of smoking to increased likelihood of cutting. Implications for practice and future research are discussed.
KEY WORDS: cutting; gay; lesbian; nonsuicidal self-injury; transgender
Historically, nonsuicidal self-injury research has focused on adult populations, on populations that experience developmental disabilities or psychoses, or on clinical samples (Brodsky, Cloitre, & Dulit, 1995).Although rates of self-injurious behavior have been increasing over the past few decades among the adolescent population (Brener, Krug, & Simon, 2000; Briere & Gil, 1998), it is only more recently that attention has turned to examining NSSI among this population (Prinstein, 2008). This study seeks to contribute to the knowledge about NSSI through analyses of secondary data in a number of ways. First, it examines the prevalence of cutting behavior among a nonclinical sample of sexual minority youths and young adults, a population of young people about which very little is known with regard to NSSI. Second, it examines correlates that predict cutting behavior to determine whether the emergent patterns mirror patterns found in NSSI research with other youths and young adult populations. Third, it examines a number of variables not currently explored in other literature with youths and adolescent populations. Finally, it examines what youths and young adults in the sample report as helping them resist urges to cut.
The language and definitions used in the literature to indicate intentional self-injurious behavior create confusion. A number of terms, including "self-inflicted injury" (Crowell et al., 2008; Welch, Linehan, Sylvers, Chittams, & Rizvi, 2008) and "deliberate self-harm" (Crawford, Geraghty, Street, & Simonoff, 2003), have been used to refer to a range of behaviors that encompass self-injury with and without suicidal intention. Research that has focused more specifically on self-injurious behavior with nonsuicidal intent has used terms such as "self-injury" (Simeon & Favazza, 2001),"self-mutilation" (Babiker & Arnold, 1997), and "self-injurious behavior" (Whitlock, Eckenrode, & Silverman, 2006; Whitlock & Knox, 2007). In this article, we use the term nonsuicidal self-injury (NSSI) (Armey & Crowther, 2008; Nock & Mendes, 2008) to indicate self-injurious behavior that occurs without the intent to die, and we use the term deliberate self-harm (DSH) to indicate self-injurious behavior that encompasses both NSSI and behavior with suicidal intent. When the behavior is even more narrowly defined, we use the specific term for that behavior, such as "cutting" or "burning."
In addition, we use the terms sexual minority youths and young adults to mean youths (ages 13 to 17 years) and young adults (ages 18 to 22 years) who report their sexual orientation as gay, lesbian, bisexual, questioning, or queer or who report their gender identity as transgender. The term questioning indicates those who are in the process of exploring their sexual orientation (Morrow & Messinger, 2006).The term queer, although historically used as an epithet against sexual minority individuals, has increasingly been adopted by youths and young adults to indicate an activist orientation toward issues of sexual and gender identity, to reject binaristic notions of sexual and gender identities, and to indicate that they experience their sexual or gender identity as fluid rather than fixed (Appleby & Anastas, 1998; Armstrong, 2002).
Prevalence estimates indicate that approximately 1.4% of the general U.S. adult population engages in NSSI (Briere & Gil, 1998; Favazza, 1996; Klonsky, Ohmanns, & Turkheimer, 2003). Rates among clinical samples, however, have been found to be significantly higher, with approximately 21% of adults and between 21% and 61% of youths in such samples engaging in this behavior (Briere & Gil, 1998; Darche, 1990). There is also evidence that NSSI has been increasing in prevalence and severity over the past 30 years (Armey & Crowther, 2008; Briere & Gil, 1998).
Rates of NSSI are significantly higher among preadolescents and adolescents than they are among adults, with 7% of preadolescents in one community sample (Hilt, Nock, Lloyd-Richardson, & Prinstein, 2008) and between 12% and 21% of adolescents engaging in NSSI (Weierich & Nock, 2008; Whitlock et al., 2006). Most findings suggest that the onset of NSSI typically occurs in early to middle adolescence (Favazza & Conterio, 1988; Woldorf, 2005) and that the behavior continues into adulthood (Favazza & Conterio, 1988). Young adults may be at an even higher risk than adolescents, with research on college students finding rates of NSSI between 17% and 38% (Gratz, Conrad, & Roemer, 2002; Klonsky & Olino, 2008), and three-quarters of those reporting NSSI having engaged in repeated episodes (Yates, Tracy, & Luthar, 2008).
With regard to gender, some studies have suggested that both DSH (Brent, 1997; Olfson, Gameroff, Marcus, Greenberg, & Shaffer, 2005) and NSSI (for repeated behaviors) (Whitlock et al., 2006) are more common among women and girls. Other studies suggest, however, that this difference is not always present or as salient as was previously thought, particularly in regard to adolescents (Gratz et al., 2002; Yates et al., 2008).Whitlock et al. (2006), for example, found gendered patterns in types of NSSI, with female college students being more likely to scratch, pinch, or cut than male college students but with male college students more likely to punch an object with the intent to harm themselves. The experiences of transgender adults and youths have been completely absent from research on NSSI, although there is limited research on the prevalence and correlates of suicidal behavior among transgender youths (Grossman & D'Augelli, 2007).
To date, little research has explored the role of race and ethnicity in NSSI, and, as a result, little is known about whether a relationship exists (Prinstein, 2008). Racial differences have been found with regard to different subtypes of NSSI (Klonsky & Olino, 2008), and Whitlock et al. (2006) found that international students were more likely than domestic students to report a single NSSI incident. Likewise, racial patterns do appear to exist in the effect that a family's reaction to the behavior has on a youth (Rosenfarb, Bellack, Aziz, Kratz, & Sayers, 2004), underscoring the importance of culturally relevant interventions with youths and their families (Trepal, Wester, & MacDonald, 2006).
PSYCHOSOCIAL CORRELATES OF NSSI
Research on the environmental risk factors associated with NSSI has focused primarily on family stress, including parent--child conflict (Brent et al., 1994), and NSSI has been found to be associated with histories of abuse and other types of early trauma (Weierich & Nock, 2008; Whitlock et al., 2006). Family environments where caregivers respond inconsistently, inappropriately, or insensitively to children's thoughts, feelings, and behaviors are also believed to play a key role in the development of NSSI (Connors, 2000; Linehan, 1993). Alexander and Clare (2004) have argued that this pattern may also include increased likelihood of development of these behaviors among people who belong to stigmatized groups, as their marginalized identities are often invalidated by their environments. Victimization at the hands of peers (Hilt, Cha, & Nolen-Hoeksema, 2008) and social exclusion (Rivers, 2000) also appear to play a role.
There is considerable diagnostic heterogeneity among individuals who engage in NSSI, from 12% who do not meet diagnostic criteria for any psychiatric disorder (Nock, Joiner, Gordon, Lloyd-Richardson, & Prinstein, 2006) to 20% who have "heightened psychiatric problems requiring more aggressive treatment" (Klonsky & Olino, 2008, p. 26). Individuals who engage in NSSI are more likely to experience features of borderline personality disorder (Klonsky et al., 2003; Whitlock et al., 2006), although approximately 40% of individuals experiencing this disorder do not engage in NSSI (Joyce et al., 2003).
Anxiety and depression are experienced more frequently by individuals who engage in self-injury than those who do not (Klonsky et al., 2003; Whitlock et al., 2006), and those who engage in self-injury are more likely to have a depression diagnosis (Weierich & Nock, 2008). Similarly, Andover, Pepper, Ryabchenko, Orrico, and Gibb (2005) found that young adults who engaged in cutting behavior had more anxiety symptoms than those who engaged in other types of NSSI behavior, and Klonsky and Olino (2008) found higher levels of anxiety symptoms among those youths who engaged in a variety of NSSI...