The experience of self-harming behaviours that inflict external injuries to the body in UK-based Bangladeshi, Indian and Pakistani women: a literature review

Abstract

Studies carried out on self-harm in the UK have consistently reported a higher level of self-harm among women with South Asian heritage resident in the UK when age-compared with other British women. The reasons for this variation are many including but not limited exclusively to family environment and gender role expectations. These studies have also shown that these women are also least likely to seek psychological support from mental health professionals again with a number of explanations including stigma against help-seeking, notions of shame and other culture-specific factors. However, previous studies have clustered this large group together based on geographical heritage, regardless of the differences between religious and heritage groups and have reported on all types of self-harming behaviours as similar and predominantly carried out quantitative studies which while providing important statistical data have not always looked at the meaning of this experience for the participants. This paper presents a review of the relevant literature within the area of self-harm among Bangladeshi, Indian, and Pakistani women living in the UK. It is noteworthy that many studies discussed are dated, this appears to reflect an apparent lack of recent interest in the topic.

Keywords:

• Self harm
• UK based
• Bangladeshi
• Indian
• Pakistani
• women

Introduction

The term self-harm has been used as a way of expressing how individuals harm themselves but very often it has not taken into account how different cultures define self. An ego-centric self means self-harm to one’s own being whereas in socio-centric cultures where the self is collectivist such an act may be seen as harming those around the individual.

Self-harm has a variety of meanings in the literature (Sutton, 2009). Other terms used in the literature consist of deliberate self-harm, self-mutilation, self-cutting and self-injurious behaviour. Nevertheless, as ‘self-harm’ is the most frequently used term (Messer & Fremouw, 2008), it will be used in this paper. The National Institute of Health and Care Excellence (NICE) defines self-harm as any act that is ‘intentional self-poisoning or injury, irrespective of the apparent purpose of the act’ (NICE, 2022, p. 6).

Although 5.5% of adults have been reported to engage in self-harm in their lifetime (Swannell et al., 2014), this figure is likely to be higher as many instances go unreported (Cooper et al., 2006). 16.7% of females engage in self-harm compared to a lower rate of 4.8% in males (Kokkevi et al., 2012),

This suggests either gender differences or differences in rates of disclosures in self-harm. Cross et al. (2014) investigated the rates of self-harm via self-poisoning in two hospitals in Central London boroughs, Lambeth, and Southwark. Their findings showed that rates of self-poisoning were exceeded in women in all ethnic categories in comparison to males. Like previous findings, they found that females were 1.5 times more likely to present with self-harm than males. Although the results did not indicate an increased level of self-harm in Asian women, it could be due to the small population of the Asian group within the catchment areas of these two hospitals.

More importantly, it has been found that the repetition of self-harm has been linked to suicide attempts (Turecki & Brent, 2016), which highlights that self-harm could be an indication of fatality. Furthermore, it has been estimated that one in twenty-five patients who visit the Accident and Emergency (A&E) services for self-harm will complete suicide in the next twenty-five years (Carroll et al., 2014), emphasising the need for a focus on self-harm.

Research on South Asian women

South Asia is a large geographical area which contains a multiplicity of nationalities, cultures, and religions. A large number of migrants to the UK originate from South Asia hence the research interest. We recognise that the term South Asian has been used in a variety of ways in research which has meant generalising from research is more complex.

Ethnic differences in self-harm

Alongside the gender differences in self-harm, research has found that self-harm is higher in South-Asian females than in other ethnic groups (Cooper et al., 2006; Marshall & Yazdani, 1999). Research has also suggested there are aspects that may generate conflict in the values and beliefs (cultural conflict) of South-Asian women living in Britain. These include a potential clash between individualistic and collectivist culture, gender role expectations, marriage, and religion (Bhugra & Desai, 2002; Bhugra et al., 1999). Pilkington et al. (2012) in a study of British Muslims of South Asian heritage found these conflicts may arise when South Asian women are required, by their family members or community, to orient their behaviours towards the community as opposed to behave in the way that they might wish to. The following section will explore the conflicting values that may trigger psychological distress in some South-Asian individuals, which may then be translated into self-harming behaviours, as a strategy to cope (Bhardwaj, 2001; Hussain & Cochrane).

As Marshall and Yazdani (1999) have highlighted, there are diverse narratives of the ways in which young Asian women perceive and engage with their culture. For example, there may be differences in the view that South-Asian culture generates a ‘clash’ as an explanation of self-harm and reject notions of South-Asian culture as in any way pathogenic. Thus, this emphasises the understanding that South-Asian culture is complex and can be experienced in diverse and perhaps contradictory ways by some South-Asian individuals. Therefore, there is a need for further culturally sensitive training, emphasising that there is no cultural template when working with South-Asian women who self-harm. Marshall and Yazdani (1999) also recommend that this could be achieved by accepting culture as complex and relational and through open discussions with service users about their meaning of self-harm.

South-Asian culture

For some South-Asian women there are defined gender role expectations (Rahman & Witenstein, 2013), with women expected to be the primary caregivers of the family (Varghese & Rae Jenkins, 2009). However, more recently, as in many countries changing social mores means that women have been required to maintain a career whilst also attending to the primary caregiving role for the family (Dasgupta, 1999; Kallivayalil, 2004). Consequently, being given a dual role has resulted in demanding and sometimes competing responsibilities (Rahman & Witenstein, 2013). Furthermore, Dwyer (2000) reported finding ‘strong’ gendered expectations of young women as the protectors of cultural and religious honour. In other words, they were examined by others in their ability to follow a specific way of behaving and their attire, particularly when they were in ‘public places’.

A review conducted by Bhugra and Desai (2002) on suicide attempts in South-Asian women found that females aged 18-24 reported an increased level of stress. It was suggested by the authors that this could be a result of the pressures associated with gender-role expectations from marriage, which can result to self-harm. It appeared that males have a greater sense of freedom in general, this could have been associated with reduced levels of psychological distress, and self-harming behaviours, in South-Asian men compared to South-Asian women (Gilbert et al., 2004; Niaz, 2003).

Some women reported that self-harm and suicide was preferred over seeking help and jeopardising the ‘honour’ of the family (also referred to as ‘izzat’) (Gilbert et al., 2004). This highlighted the link between South-Asian cultural values and beliefs and possible self-harm; therefore, it is crucial to study this group of women.

Self-harming behaviour among South-Asian women

Epidemiological studies have shown higher rates of self-harm particularly among individuals from a South-Asian ethnicity in the UK (Marshall & Yazdani, 1999). More specifically, it has been reported that South-Asian women are 1.5 times more likely to engage in self-harming behaviours than white women (Cooper et al., 2006).

However, one aspect that has been raised is the conflict and tension that is often encountered by South-Asian individuals when negotiating their two ethnic identities and when the two cultural norms are not experienced as compatible with each other, whereby abiding by one cultural value would directly prevent adherence to the other (Dwyer, 2000). For example, the western culture may promote freedom of choice for the individual to choose a career path, while their South-Asian parents may expect them to pursue a career path they want their child to, which could lead to an internal conflict between what they want to do versus what their parents expect from them (Ngo, 2006).

Due to these divergences, one of the difficulties that second-generation South-Asians faced was related to the development of their own cultural identity. This was due to the mismatch between the values of the South-Asian culture with those of the British western culture (Babiker and Arnold, 1997), referred to as ‘culture conflict’. The challenge for South-Asians living in the UK can be viewed as a conflict between the collectivist culture of their parents and wider community versus the western culture related to individualism (Triandis, 1989). This can generate difficulties with their decision to act either in line with the beliefs and values expected from their South-Asian community or that of the wider western culture. However, it can be argued that further studies are required on South-Asian women to comprehensively understand this cultural conflict which tends to reappear in different studies.

Research on self-harm among South-Asian women

There is limited research on self-harm among South-Asian individuals, however, the common finding suggests that South-Asian women are at a higher risk of self-harm in comparison to individuals from other ethnic backgrounds. For example, Al-Sharifi et al. (2015) reviewed ten articles on the rates of self-harm, clinical characteristics, method of self-harm and risk factors among different ethnic groups. They concluded that ethnicity should be taken into consideration when treating individuals due to the evident differences from cultural pressures. Further, it was found that factors that may protect or predispose the individual to self-harm (i.e. religion, mental health, coping styles) also differ between groups, therefore, the authors recommended that ethnicity be taken into consideration when self-harm is concerned (Al-Sharifi et al., 2015).

Additionally, Biswas (1990) carried out a retrospective study, investigating the case notes of 38 Asian patients and 34 white patients. The participants were aged between 13 to 17 years and had attended Accident and Emergency (A&E) department in Bradford (England), after an episode of self-poisoning. Although she found that the gender ratios of both samples were alike, she found that 36% of South-Asian participants reported experiencing a cultural clash, whereby there was a conflict between the western and South-Asian cultural expectations as a precipitating factor prior to self-harming. These cultural clashes were related to conflict over traditional customs from the South-Asian culture as a reason for self-poisoning (Biswas, 1990). Therefore, she concluded that culture and cultural clash plays an important role in self-harming behaviours in South-Asian women.

Moreover, Husain et al. (2006) carried out a review on the occurrence of self-harm in British South-Asian women and the issues that add to these rates of self-harm. They found that 16–24 year-old South-Asian women were more likely to self-harm than white women. They also found that the rates of self-harm were higher in South-Asian women than South-Asian men in all age groups. When explored further they found that the South-Asian women who self-harmed were generally younger, more likely to be married and less likely to be employed. They also reported more interpersonal difficulties with family members. The authors highlighted that most of the studies they reviewed did not consider the diversity that prevails in the South-Asian community, which could mean that the specific needs of each South-Asian group had not been considered and thus mental health services cannot be appropriately tailored to this overlooked group.

Additionally, the link between culture and self-harm in South-Asian women was explored by Bhugra et al. (1999). The Asian Cultural Identity Schedule (ACIS) was used, and this included 106 questions on their cultural identity. The ACIS was generated based on a discussion with leaders from the local community and was piloted on 12 students from an Asian background. It examined 12 areas of cultural identity such as religion, language, marriage, employment and housing, leisure, food and shopping, aspirations, self-attitudes. Bhugra et al. (1999) used this scale to interview 22 South-Asian adolescents who self-harmed and their parents and 54 South-Asian women who had self-harmed. Half the participants were in the control group and the other half were subjects. A comparison was made of the ACIS scores. The researchers found that the women who had inflicted self-harming behaviours were less traditional (i.e. scored lower on the ACIS) in comparison to the control group. Furthermore, these women were also less likely to have traditional values and more likely to experience family conflict and interracial relationships when compared to matched controls. The authors concluded that the ACIS had successfully highlighted the role of cultural identity in self-harming behaviours, however the study has a few limitations which will now be discussed. One limitation of the study could relate to the fact that the ACIS interview captured the attitudes towards cultural identity as opposed to how participants chose to behave. Therefore, while understanding the attitudes towards South-Asian culture is important, the ACIS interview did not aid in our understanding of how South-Asian women chose to behave given the conflicting values and beliefs they are presented with by the South-Asian culture and the western society that they were living in. Additionally, the sample was made up of those in crisis, therefore only those who had sought professional support were included in the sample and thus the sample may not capture the self-harming behaviours of those that do not seek professional help for their self-harm. This may be problematic as it reduces our understanding of South-Asian women who self-harm but do not seek psychological support and thus there could be various barriers preventing South-Asian women from seeking professional help.

Furthermore, the use of the ACIS scale meant that participants responses were limited to the items deemed important by the scale. For example, the ACIS scale did not include attitudes on gender role expectations or living with in-laws which could also generate tensions in cultural identity. Therefore, important nuances that exist in South-Asian culture may not have been captured by the ACIS, thus this may limit our knowledge and ability to support these South-Asian women. The above studies allude to ideas indicative of self-harm in South-Asian women in the cultural context. As South-Asian females have been found to be at an increased risk of self-harm and culture can be seen to play a role in self-harming behaviours, the following paragraphs will explore the literature that has investigated self-harm in South Asians.

Cooper and colleagues found that South-Asian females were five times more likely to self-harm compared to South-Asian males (Cooper et al., 2006) whereas Bhugra et al. (1999) had reported a seven times differential. Cooper et al. (2006) also found that South Asian females had the highest rate of self-harm in comparison to white females. Although the reason for this was not clear, the authors concluded that this increase was due to interpersonal problems with family members which were culturally influenced.

Aktar (2022) utilises interpretative phenomenological analysis on semi-structured interviews with eight participants to identify four super-ordinate themes and eleven sub-ordinate themes. The super-ordinate themes were powerlessness, mitigation, self-harm is wrong, and cultural values and beliefs. The study provides new insights on the impact of South-Asian cultural values and beliefs on the experience of self-harm in South-Asian women, highlighting that the experience of self-harm is a complex one, whereby the impact of the South-Asian cultural values and beliefs on the self-harm experience needed to be examined.

Similarly, Mafura and Charura (2022) investigated the lived experiences of South Asian women raised in the UK regarding the cultural concept of ‘Izzat’ and its relation to self-mutilation. Semi-structured interviews were conducted with 12 participants, and the results were analysed using interpretative phenomenological analysis. The findings suggest that Izzat is central to cultural discord experienced by the participants and a factor in their self-harm behaviours. The study identifies five themes related to self-harm among South Asian women, including struggles with cultural identity, trauma, distraction, communication of pain, and perceived punishment. The study highlights the importance of understanding cultural diversity and introjected cultural expectations and their impact on trauma and clinical practice. Future research should focus on exploring trauma-informed and culturally sensitive approaches to working with those impacted by Izzat and maintaining family honour.

Reasons for self-harm amongst South-Asian women

Research suggests that the act of self-harm may correspond with the struggle to discuss the difficulty in more healthy ways (Chew-Graham et al., 2002). As noted above, South-Asian women reported ‘izzat’ (honour and respect for the family reputation) as huge repellent in seeking help when in psychological distress (Chew-Graham et al., 2002). South-Asian women have reported that the concept of ‘honour’ is given high importance and placed above their own happiness and were taught that they could not behave in a way that would bring shame to the family, therefore, they would not seek help when they were in distress (Chew-Graham et al., 2002). Other studies, including Aktar and Tribe (2023a, 2023b) have highlighted the experiences of South-Asian women who have not all sought psychological support. This can be achieved through purposive sampling recruitment, which would be inclusive of participants who have not sought support in the past as well as those who have.

The reason for the higher prevalence in self-harm of females could be that men are more likely to externalise their difficulties whereas women tend to internalise their emotions and harm themselves intentionally (Crick & Zahn-Waxler, 2003; Laye-Gindhu & Schonert-Reichl, 2005). Also, one explanation of gender differences in self-harm could be that Eastern sociocultural expectations created restrictions on opportunities for females and decreased their ability to have a ‘voice’ (Laye-Gindhu & Schonert-Reichl, 2005). Thus, one of the reasons that South-Asian women experience an increased level of distress and difficulty could be due to the pressures placed on them from their families and communities (Cooper et al., 2006).

Bhardwaj (2001) explored the reasons as to why South-Asian women self-harmed, using interviews and guided focus groups. One common theme that emerged was that many women reported using self-harm (e.g. cutting, burning & overdosing) to ‘cope’ with their distress. They explained that self-harm was particularly used when they felt they could not articulate their distress towards others. One concept that emerged was the idea of power and control. For example, they felt that they had no control over their lives but the one thing that they could control and had power over was their own body, thus self-harming enabled them to regain control (Bhardwaj, 2001). The researcher ended with a recommendation of a need for culturally competent services and raising awareness, particularly in London, where the study was carried out. London is one of the most multi-cultural places in the UK with 20.7% of individuals identifying with an Asian ethnicity (Gov.uk, 2022), an increase from 18.5% in the last census. This recommendation was made because the authors had seen that the source of distress for these women which then resulted to self-harming behaviour was due to psychological distress around ‘parental, family and community related oppressions’, whereby issues related to ‘izzat’ and ‘honour’ generated a perceived burden for these South-Asian women. Further, they described that the gender inequalities placed on them by their parents acted as a contributory factor to self-harm. This highlighted that the unattainable standards and expectations that South-Asian women felt they were expected to live up to, generated emotional distress and thus they self-harmed to cope with it. Therefore, their recommendation made an emphasis on the need for mental health professionals to be aware of such nuances that are experienced by these women. However, the authors did not state the basic details of the study such as the number of participants or the exact methodology used for analysis. Therefore, readers are unable to understand the process used and thus the themes and conclusions made become less clear.

Another qualitative study by Chew-Graham et al. (2002) looked at the experience of psychological distress and self-harm in South-Asian women, through four focus groups with five to twelve women each. The researchers took notes during the focus group discussions and analysed the data in accordance with the codes of Framework Analysis, based on Ritchie and Spencer (1994). Upon analysis, the researchers found three themes: ‘Izzat’, Community grapevine and Racism. Izzat, meaning the honour and respect for their family reputation, was placed at a high position, over their happiness and wellbeing in South-Asian women. The participants stated that it played a role in coercing them to remain silent about their psychological distress, refraining from seeking psychological help as this would look bad on the family reputation and therefore, they had found other forms of maladaptive coping strategies such as self-harm. The second theme, the role of the community’s involvement, meant that South-Asian females reported having limited privacy. They explained that if they had been seen to be ‘behaving inappropriately’ then this information was spread around the community. They felt that this led to a sense of isolation, as they did not have any appropriate services to seek support. Finally, they felt that mental health professionals saw them as being lesser than their white counterparts; therefore, they were reluctant to access mainstream services. These when combined, contributed to psychological distress and self-harm (Chew-Graham et al., 2002). This indicated the significance of exploring the individual’s broader context and culture on understanding self-harm, as culture in South-Asian women played a crucial role in self-injurious behaviour (Chew-Graham et al., 2002).

Additionally, Marshall and Yazdani (1999) carried out another qualitative analysis of self-harm among South-Asian women with an aim of developing and improving services in London. They interviewed seven South-Asian women with a history of self-harm and eight service providers, with a focus on exploring the meanings given to self-harm. They also discussed the broader environment within which participants located their self-harming behaviour, which included broader discussions of whether and how self-harm related to factors of the South-Asian culture. Marshall and Yazdani (1999) found four meanings of self-harm: a release from distress, ending it all, effecting change and taking control. Firstly, ‘a release from distress’ was associated with emotional pain relief, whereby emotional suffering was released. For these participants, self-harm was viewed as a coping strategy to enable ‘day-to-day’ survival. Secondly, ‘ending it all’ referred to suicide attempts which focused on the self and thus allowing the body to ‘escape’ from the desperate situation. Thirdly, ‘effecting change’ referred to self-harm as an act of expression of disclosure, and thus communicates a message to others (e.g. family members) for ‘outside’ support. Finally, taking control referred to where a participant experienced a perceived lack of control and viewed cutting or overdosing to regain this control. The authors concluded that clinicians working with South-Asian women should prioritise their meaning and the needs which may be located within the socio-cultural environments.

Marshall and Yazdani (1999) provided a deeper understanding of the experience and meaning that South-Asian women attributed towards their self-harming experience at a qualitative level. However, the participants method of self-harm varied from cutting, to not eating, which could question the homogeneity of the sample. This means that the small number of participants studied were not particularly similar in their method of self-harm. For example, it is difficult to see how a participant who engaged in self-harm via cutting would share a lived experience with a participant who had been restricting their eating for long periods of time. This lack of similarity may have made it difficult to examine convergences and divergences in detail during the analysis stage.

Additionally, Gull and Najam (2021) examined the role of psychosocial factors as predictors of self-harm in 120 participants in Pakistan. They explored the self-harm, quality of life, self-esteem, emotional intelligence, depression, anxiety, and stress. They found a strong positive correlation in the Depression, Anxiety and Stress scores and a negative correlation with self-esteem, emotional intelligence, and quality of life. This highlights the multi-faceted reasons for self-harm in South-Asian women.

Methods of self-harm

Borrill et al. (2011) found that 53% of participants had reported engaging in self-harm by scratching their body and 46% had reported cutting, which can indicate that external injuries to the body are the most common forms of self-harming behaviour in South-Asian women. As studies have not previously made this distinction, it is important to consider the differences in the types of self-harming behaviour to further add to our understanding of the complexity of this phenomenon. This would ensure that participants are describing and making meaning of a similar phenomenon. The authors also note that the definition of self-harm used in the study did not include behaviours such as substance misuse, excessive exercising, or overworking, which may be equally harmful to the individual. Thus, future studies could potentially explore these unconventional methods of ‘self-harm’.

Furthermore, many studies have suggested that South-Asian women do not seek help for their self-harming but rather seek help at crisis point. Therefore, the following section will aim to discuss the reasons for non-disclosures, help-seeking, and coping methods (including traditional interventions) used to cope with distress by South-Asian women.

Help seeking and coping methods

Closely connected to disclosures of self-harm are difficulties surrounding help-seeking following engagement in self-harming behaviours. Help-seeking refers to the act of requesting support or assistance with self-harming behaviour. Borrill et al. (2011) looked at the coping styles and self-harm in a range of ethnic groups. They found that Asian participants reported the highest level of avoidance coping methods than other ethnic groups. Thus, this group may be more likely to use avoidance as a coping strategy and less likely to seek help. However, Borrill and colleagues looked at ‘Asian’ group, but it may be interesting to see whether findings would differ if the ‘Asian’ group was categorised into subgroups.

Further, it has been reported that South-Asian women use traditional methods to cope when in distress. Research by Dein and Sembhi (2001), using a mixed methodology, explored traditional healing strategies in 25 South-Asian psychiatric patients. They found that 28% of the patients used a traditional healer when they were in distress, which included going to seek advice from a religious leader or eating or drinking specific foods. They also examined five case studies and found that patients had turned to traditional healing methods in conjunction with western interventions. Participants reported that one aspect they liked about traditional methods was the inclusion of their family members, whereas western treatment typically excluded family involvement, thus they preferred traditional over western methods. This highlights the importance of systemic interventions for South-Asian individuals (Dein & Sembhi, 2001). However, this was explored for the psychiatric and physical illnesses, therefore, further research is required on the use of traditional methods of treatment for psychological distress, particularly self-harm. Furthermore, the extent to which involving family members for the treatment of self-harm in South-Asian women is questionable, particularly as research has shown that South-Asian women would prefer to not disclose their self-harming behaviours to family members (Chew-Graham et al., 2002).

Additionally, Gilbert et al. (2004) carried out research using three focus groups with women who identified as being ‘Asian’. They were presented with four different scenarios which the researchers believed would tap into the issues related to izzat, shame, subordination, and entrapment, and they were asked questions to generate conversation around the scenarios. Gilbert et al. (2004) found that some women reported that self-harm and suicide was preferred over seeking help and jeopardising the family ‘izzat’ (honour and respect for the family reputation). This highlighted the importance of concealing any information that could endanger the family reputation. It also alluded to ideas around shame and loss of izzat as key reasons for South-Asian women not utilising mental health services. This means that further research is required to understand how these issues about shame and izzat can be overcome so that South Asian women are able to seek psychological support for their self-harming behaviour and they are not just waiting for crisis point to seek professional help.

Although studies have shown that South-Asian females are at a higher risk of self-harm and less likely to seek professional support (Cooper et al., 2006), it has also been reported that South-Asian women would only seek help at the point of crisis, therefore early intervention opportunities are missed (Chew-Graham et al., 2002).

Conclusion

The existing literature on self-harm among South-Asian women has been discussed. It indicated that due to the limitations in the existing studies, the literature cannot explain the full complexities of this phenomenon in this group and studies on help-seeking and disclosures have shown that these women do not seek psychological support for self-harm. Having discussed the impact of cultural elements on South-Asian women’s experience of self-harm, it can be inferred that there are cultural factors that may influence their well-being, which is linked to self-harm. In essence, some South-Asian women may experience pressures from their culture, which then has an impact on their wellbeing and can be linked to self-harming behaviour. The existing literature has predominantly used quantitative research and of the limited qualitative studies carried out, they have not always considered the meaning of the experiences of self-harm. Furthermore, it has clustered large ethnic groups together regardless of the differences between them. Finally, existing studies have looked at all types of self-harming behaviours as similar, therefore future research is needed to explore self-harming behaviour that inflicts external injuries to the body (e.g. cutting, burning & scratching the skin). It is also worth noting that many studies in this review are dated, which is indicative of the lack of up-to-date research. Therefore, further studies are required specifically on this group to explore the impact of South-Asian culture and psychological distress, particularly self-harm.

Disclosure statement

No potential conflict of interest was reported by the author(s).