Abstract
In Western research, self-injurious behaviors are commonly viewed as “feminine” behavior. In this present study, using the data from a survey administered to 960 first- and second-year students in Xi’an Jiaotong University in China, the self-injurious behaviors among college students are analyzed by sex. The results reported that the average prevalence of self-injurious behaviors among male students is 35.2%, higher than the 20.4% observed among female students (p < .1), and the average frequency of severe self-injurious behaviors among male students is 0.4, higher than the 0.18 reported among female students (p < .05). Gender role conflicts and verbal violence are strongly associated with male students’ self-injurious behaviors, whereas gender role conflicts and verbal, visual, and sexual violence are strongly associated with female students’ self-injurious behaviors. This suggests that self-injurious behaviors among college students in China constitute, to some extent, a boy crisis that can be well explained by gender role conflicts. In addition, verbal violence leads to self-injurious behaviors among both male and female students, whereas visual and sexual violence lead to self-injurious behaviors only among female students.
Introduction
In Western research, self-injurious behaviors are commonly viewed as “feminine” behavior that is most likely to occur among female adolescents aged 15 to 19 years (Van Camp, Desmet, & Verhaeghe, 2011). Before 2000, the consistent viewpoint was that the prevalence of self-injurious behaviors among female adolescents was from 1.5 to 3 times greater than among male adolescents (Yates, 2004). After 2000, this estimate has been changing: Some scholars insist that there is a sex difference in the prevalence of self-injurious behaviors among adolescents (Claes, Vandereycken, & Vertommen, 2007; Hawton, Rodham, Evans, & Weatherall, 2002; Laye-Gindhu & Schonert-Reichl, 2005; Muehlenkamp & Gutierrez, 2004; Whitlock, Eells, Cummings, & Purington, 2009), while other scholars have reported no sex difference in the prevalence of self-injurious behaviors among adolescents (Gratz, Conrad, & Roemer, 2002; Hilt, Nock, Lloyd-Richardson, & Prinstein, 2008; Klonsky & Muehlenkamp, 2007; Muehlenkamp & Gutierrez, 2004; Nock, Joiner, Gordon, Lloyd-Richardson, & Prinstein, 2006). Others have reported distinctly “feminine” and “masculine” manners of self-injuring, for example, women tend to do smaller cuts in hidden places with sharp implements (e.g., X-acto blades, straight-edge blades, and broken razor cartridges) and to hide their behavior; while men are more inclined to do larger, deeper cuts and burns on their chests, their upper arms, and more noticeable locations with rough, serrated knives or rusty nails and to be open about their injuries (Adler & Adler, 2011; Laye-Gindhu & Schonert-Reichl, 2005; Van Camp et al., 2011).
Studies in China, however, tell yet another story: The prevalence of self-injurious behaviors among male adolescents is significantly higher than among female adolescents. For example, P.X. Wang, Lu, and Li’s (2007) study among 371 college students in China reported that the prevalence of self-injurious behaviors is 18.4% among males and 13.8% among females but without statistical significance. Another study conducted among students from 12 universities reported a significantly higher prevalence of self-injurious behaviors among male students (39.1%) than among female students (19.5%; S. J. Wang, 2010). Huang, Peng, Zhan, and Ding’s (2011) study of 1,525 students from 8 universities in Hunan of China reported the same pattern, with the prevalence of self-injurious behaviors among male students (12.19%) being significantly higher than among female students (8.19%). Although these studies in China suggest a different gender pattern for self-injurious behaviors compared to that in western countries, they do not provide any reasonable explanations.
Gender role conflicts are defined as a psychological state in which the socialized male gender role has negative consequences for the person and others (O’Neil, 2008). Although criticized for providing a “static” view of masculinity and health behaviors as well as blurring their relationship with personalities (Gough & Robertson, 2010; O’Neil, 2008; Payne, Swami, & Stanistreet, 2008), this concept is commonly used to explain suicidal behaviors among adolescents (Cohen, 1991; Fitzpatrick, Euton, Jones, & Schmidt, 2005; Pinhas, Weaver, Bryden, Ghabbour, & Toner, 2002). Self-injurious and suicidal behaviors, however, reported not only strong similarities but also very small differences. Research has indicated that a large number of self-injurers admit that they have also been suicidal (Firestone & Seiden, 1990; Klonsky & Muehlenkamp, 2007; Muehlenkamp & Gutierrez, 2004; Nock et al., 2006). Despite the similarities, research has also revealed obvious differences between the two types of behavior in terms of embodiment, traits, and willingness (Klonsky & Muehlenkamp, 2007; Messer & Fremouw, 2008; Muehlenkamp, 2005). The relationship between gender role conflicts and suicidal behaviors and the relationship between suicidal and self-injurious behaviors signify that the gender patterns in self-injurious behaviors among Chinese adolescents as a boy crisis are probably associated with gender role conflicts.
Researchers in Western countries and China have also reported that self-injurious behaviors among adolescents are strongly associated with their negative moods, psychological traits, and interpersonal interactions (Crowell et al., 2008; Ross & Heath, 2003; Suyemoto & MacDonald, 1995; S. J. Wang, 2010). Violent experiences not only lead to negative moods and psychological states such as depression, anxiety, and hostility among adolescents (Bagley, 1991; Briere, 1992; Mercer, 1988; Tipper, 1997; Welsh, Archambault, Janus, & Brown, 1995) but also strongly represent the negative interpersonal interactions in which adolescents are involved. The violence that adolescents experience commonly arises from their interpersonal relationships in various environments, such as with their parents, teachers, or peers; and it may be classified into various forms, such as physical violence (e.g., beat or hit, etc.), verbal violence (e.g., scold, curse, etc.), sexual violence (e.g., sexual abuse, sexual assault, etc.), visual violence (e.g., seeing or witnessing violent events or scenes occurred among other persons, etc.), and cold violence (e.g., coldly treated, unfriendly treated, neglected, etc.; Briere, 1992; Carlson, 1990; Lynn & O’Neill, 1995; Welsh et al., 1995). Some research has reported that physical or sexual abuse during childhood is significantly associated with later self-injurious behaviors among adolescents (Briere, 1992; Lynn & O’Neill, 1995; Welsh et al., 1995).
Using the data from a survey conducted among first- and second-year college students in a university in western China, this present study aimed to analyze the sex difference in self-injurious behaviors among college students and to try to explain the self-injurious behaviors among college students by sex through looking at gender role conflicts and violent experiences.
Data and Method
Survey and Samples
Research has identified that adolescents aged 15 to 19 years are most likely to carry out self-injurious behaviors (Canadian Institute for Health Information, 2011); therefore, using the equal proportion sampling method, this present study selected first- and second-year college students in the normal age range as the sample. The data were collected in September and October of 2013 via “A Survey for Adolescents’ Health Risk Behaviors” conducted at Xi’an Jiaotong University. Students in 4 disciplines—science, engineering, medicine, and literature—and from 11 schools of study—science, mechanics, electrical engineering, dynamic, telecommunications, life science, spaceflight, medical science, economics and finance, public policy and administration, and humanities—took part in the survey.
Before the formal survey, the researchers obtained institutional review board approval from the School of Medical Science at Xi’an Jiaotong University. The counselors in each school were entrusted to administer the questionnaires, and the participants were asked to answer the questionnaires by themselves; finally, the counselors were responsible for collecting the questionnaires from the students. During the process, participants were asked to fill out the informed consent forms and to sign their names, as well as being informed of their right to cancel participation in the survey at any time. The questionnaires did not ask for participants’ names for purposes of privacy protection. Each respondent was given a well-designed bookmark as the incentive for completing the questionnaire. Out of 1,200 questionnaires issued, 960 were returned. The three schools from which the most students participated were medical science, telecommunications, and mechanics, followed by electrical engineering, life science, public policy and administration, and humanities. The mean age for the respondents is 18.69 years, with the eldest being 24 and the youngest 15 years; in addition, 33.2% of respondents are from rural areas and 67.8% from urban areas.
Measurements
Adolescents’ Self-Injurious Behaviors
To measure adolescents’ self-injurious behaviors, the Non-Suicidal Self-Injury Assessment Tool (NSSI-AT) developed by Janis Whitlock and Amanda Purington (2007) was adopted. The results of the data analysis reported Cronbach’s alpha coefficient for this tool is .77, indicating a good reliability. The specific items measured are as follows:
Types of self-injurious behaviors: A binary variable, this was measured with 0 = no, 1 = yes, in answer to the question “Have you ever done any of the behaviors with the purpose of intentionally hurting yourself but without the intention of ending your life?” So that respondents would easily understand, 14 specific self-injurious behaviors were defined, such as “severely scratched or pinched with fingernails or other objects to the point that bleeding occurs or marks remain on the skin; cut wrists, arms, legs, torso or other areas of the body . . .” and so on (see the NSSI-AT; Whitlock & Purington, 2007).
The frequency of self-injurious behaviors: An ordinal variable, this was measured on a 7-point scale (1 = only once, 2 = 2-3 times, 3 = 4-5 times, 4 = 6-10 times, 5 = 11-20 times, 6 = 21-50 times, 7 = more than 50 times), in answer to the question “Approximately on how many total occasions have you intentionally hurt yourself?”
Severe self-injurious behaviors: A binary variable, this was measured with 0 = no, 1 = yes, in answer to the question “Have you ever intentionally hurt yourself more severely than you expected?”
The frequency of severe self-injurious behaviors: An ordinal variable, this was measured using a 4-point scale (1 = once, 2 = 2-3 times, 3 = 4-5 times, 4 = more than 5 times), to answer the following question: “How many times have you intentionally hurt yourself more severely than you expected?”
Wounded location: This is a categorical variable, measured with 14 items (e.g., 1 = wrists, 2 = hands, 3 = arms), in answer to this question: “On what areas of your body have you intentionally hurt yourself?” (see the NSSI-AT; Whitlock & Purington, 2007).
Ways of self-injurious behaviors: A categorical variable, this was measured by the above-mentioned 14 specific self-injurious behaviors (see the NSSI-AT; Whitlock & Purington, 2007).
Motivation for self-injurious behaviors: A categorical variable, this was measured with 14 items (e.g., 1 = A friend suggested that I try it, 2 = I read about it on the Internet and decided to try it) in answer to the following question: “Which of the following descriptions best describes your motivations for first intentionally hurting yourself?” (see the NSSI-AT; Whitlock & Purington, 2007).
The consequences of self-injurious behaviors: A categorical variable, this was measured with six items (e.g., 1 = relationships that are important to me, 2 = my ability to complete school or work obligations), in answer to the following statement: “The fact that I intentionally hurt myself interferes with . . .” (see the NSSI-AT; Whitlock & Purington, 2007).
Gender Role Conflicts
Gender role conflicts scales are generally used to measure conflicts facing males who are experiencing gender role adaptation that is relevant to the male’s gender role, such as the Gender Role Conflict Scale (O’Neil, Hemls, Gable, David, & Wrightsman, 1986), or conflicts facing females who are in male-dominant occupations, such as the Athletic Sex Role Conflict Inventory developed by Sage and Loudermilk (1979) and the Sex Role Conflict Scale for the workplace (Koberg & Chusmir, 1987). Based on O’Neil et al.’s (1986) study, Blazina, Pisecco, and O’Neil (2005) developed a Gender Role Conflict Scale for Adolescents, which is only for male adolescents. A shortage of scales remains for simultaneously measuring gender role conflicts in both males and females.
Therefore, this study is based on the Masculine Gender Role Stress by Eisler, Skidmore, and Ward (1988) and the Feminine Gender Role Stress from Gillespie and Eisler (1992). These were adapted with cross-cultural and cross-population revisions according to experts’ reviews and ratings to make them suitable for measuring gender role conflicts among college students in the context of China. Finally, a 40-item gender role conflicts scale was obtained for male college students and a 35-item gender role conflicts scale for female college students. The results of the data analysis reported Cronbach’s alpha coefficients for males as .92 and for females as .88, indicating a good reliability for the two scales.
Violent Experiences
Based on previous qualitative research and the literature review on existing studies (Briere, 1992; Carlson, 1990; Lynn & O’Neill, 1995), the present study classified violent experiences among adolescents into five categories: verbal violence, physical violence, visual violence, cold violence, and sexual violence. These are respectively measured by yes or no answers (0 = no, 1 = yes) to the question “Have you experienced any forms of verbal violence/physical violence/visual violence/cold violence/sexual violence?” The results of the data analysis reported Cronbach’s alpha for this measurement is .67, indicating an acceptable reliability.
Other relevant variables such as age, grade, major, registered permanent residence, origin, and parents’ education were also included.
Analysis Strategies
First, a comparison analysis was conducted on the prevalence, frequency, wounded location, forms, motivation, and consequences of self-injurious behaviors among college students by sex. Based on the results, the binary logistic analysis method was further adopted, with the likelihood of self-injurious behaviors as the dependent variable, to construct a series of associated factors models for self-injurious behaviors among college students by sex.
Results
The sex differences in self-injurious behaviors among college students are presented in Tables 1 and 2. As reported in Table 1, the prevalence of self-injurious behaviors is 35.2% among male students, higher than the 20.4% reported among female students, which is significant at a level of p < .1; at the same time, the frequency of severe self-injurious behaviors among male students is 0.4, significantly higher than the 0.18 reported among female students (p < .05). However, there is no significant sex difference in the frequency of self-injurious behaviors or the prevalence of severe self-injurious behaviors.
The Gender Difference in Prevalence and Frequency.
p < .1. *p < .05.
The Gender Difference in Wounded Locations, Forms, Motivations, and Consequences.
As reported in Table 2, there are slight sex differences in the wounded locations: The most common for both are the hand, arm, mouth, lips or tongue, and thighs. For males, the wounded locations include the head, while for females, they include the wrist. The forms of male students’ self-injurious behaviors tend to be more aggressive and violent, whereas for females they tend to be milder. Concerning motivations for self-injurious behaviors, rage toward themselves and others is the main motivation for both males’ and females’ self-injurious behaviors. Motivations for self-injurious behaviors among male students also included “drunk or high,” whereas among female students they included peer influences (e.g., “I did it because I had friends who did it, and I wanted to fit in”). The consequences for self-injurious behaviors agree almost entirely in both genders, including mainly negative impacts on relationships, self-worth or self-esteem, school education or work obligations, taking care of themselves, and hobbies.
The analysis results relating to factors associated with self-injurious behaviors among male college students is presented in Table 3. As reported in Table 3, in Model 1, gender role conflicts have a significantly positive impact on male students’ self-injurious behaviors (1.03, p < .001).
The Impacts of Gender Role Conflicts on Male Students’ Self-Injurious Behaviors.
p < .1. *p < .05. **p < .01. ***p < .001.
When the variables of violent experiences are incorporated into Model 2, the impacts of gender role conflicts on male students’ self-injurious behaviors remain almost unchanged in significance, direction, and coefficient size, whereas verbal violence has a positive impact on male students’ self-injurious behaviors (1.45, p < .05).
When the control variables are included in Model 3, the impacts of gender role conflicts and verbal violence on male students’ self-injurious behaviors remain almost unchanged in significance, direction, and coefficient size, whereas age and grade have a significant impact at a level of p < .1 (0.12, 1.61).
If the variables are included in the models step by step, the explanation power increases. The Cox and Snell R2 and Nagelkerke R2 for Model 1 are .05 and .08, respectively; they increase to .11 and .16 in Model 2 and to .13 and .20 in Model 3, indicating that gender role conflicts, verbal violence, and the control variables can well explain male students’ self-injurious behaviors.
The results obtained from the analysis on factors associated with self-injurious behaviors among female college students is presented in Table 4. As reported in Table 4, in Model 1*, gender role conflicts have a significantly positive impact on female students’ self-injurious behaviors (1.02, p < .05).
The Impacts of Gender Role Conflicts on Female Students’ Self-Injurious Behaviors.
p < .1. *p < .05. **p < .01. ***p < .001.
When variables of violent experiences are included in Model 2*, the impact of gender role conflicts on female students’ self-injurious behaviors remains almost unchanged in significance, direction, and coefficient size, whereas among the newly added variables of violent experiences, verbal violence, visual violence, and sexual violence all have a significantly positive impact on female students’ self-injurious behaviors (verbal: 1.71, p < .01; physical: 1.72, p < .001; sexual: 6.03, p < .1).
When the control variables are included in Model 3*, the impact of gender role conflicts on female students’ self-injurious behaviors remains almost unchanged. While the variables of violent experiences on female students’ self-injurious behaviors remains unchanged in direction, they increase a little in significance and in coefficient size (verbal: 1.90, p < .01; physical: 2.05, p < .001; sexual: 1.03, p < .01).
When the variables are incorporated into the models step by step, the explanation power increases. The Cox & Snell R2 and Nagelkerke R2 in the models are only .01 and .02, indicating that gender role conflicts can explain only a very tiny part of female students’ self-injurious behaviors; when the variables are included in the models, the Cox & Snell R2 and Nagelkerke R2 in Model 2 are increased to .12 and 19, and in Model 3, to .17 and .16, indicating that the variables of violent experiences can well explain female students’ self-injurious behaviors.
Discussion and Conclusions
The descriptive analysis above demonstrates that as reported in the data, the prevalence of self-injurious behaviors and frequency of severe self-injurious behaviors among male students are significantly higher than among female students, which accords with other similar research (Huang et al., 2011; P.X. Wang et al., 2007; S. J. Wang, 2010) but is contrary to findings from studies in Western countries concerning sex differences in the prevalence of self-injurious behaviors (Hawton et al., 2002; Whitlock, Eckenrode, & Silverman, 2006), as well as the suicidal facts by sex reported in China: The suicide rate in China is higher among women than men, and this was highlighted in a World Health Organization report (Weiyuan, 2009). Our findings, however, accord with studies on the prevalence of suicidal behaviors in Western countries: Data from the National Center for Health Statistics reported that the suicidal rate among boys aged 15 to 25 years is 5 times that among girls (Kleinfeld, 2009). This may indicate that to some extent this is a boy crisis on self-injurious behaviors in China as males apparently face a higher possibility of engaging in self-injurious behaviors, which is also evidence for the viewpoint that a psychological crisis is more likely to occur among males (Li & Zhao, 2010). At the same time, there are some slight sex differences in the wounded locations, forms, and motivations for self-injurious behaviors among college students; in other words, self-injurious behaviors are more aggressive and violent among male students than among female students.
The results of the analysis on factors associated with self-injurious behaviors identified that gender role conflicts have a positive impact on self-injurious behaviors among both male and female college students, but the significance and the explanation power are different between males and females. The impact of gender role conflicts on male students’ self-injurious behaviors is significant (p < .001), and the explanation power is also large (Cox & Snell R2 = .05, Nagelkerke R2 = .08), indicating that gender role conflicts can well explain male students’ self-injurious behaviors; among female students, by way of contrast, gender role conflicts affect female students’ self-injurious behaviors to some extent but with limited significance and explanation power (p < .05; Cox & Snell R2 = .01, Nagelkerke R2 = .02), indicating that variables other than gender role conflicts may explain female students’ self-injurious behaviors. This not only supports the viewpoint that “the suicide-related behaviors, like health-behaviors more generally, are influenced by (and influence) demonstrations of masculinities and femininities” (Payne et al., 2008), but also suggests that in the context of Chinese culture and reality, gender role conflicts is the most important variable for providing a good explanation of the “boy crisis” in self-injurious behaviors, which is apparent in previous research. For example, the dimensions of “competition” and “motivation for success” are the protective factors for male adolescents’ suicidal behaviors, while “emotional disclosure with anxiety or negativity” are risk factors for male adolescents’ suicidal behaviors (Galligan, Barnett, Brennan, & Israel, 2010). Other studies have also pointed out that the traditional male gender role appears to increase the risk of suicidal behavior or other health risk behaviors in men by undermining their mental state and by inhibiting the protective factors of help seeking and social support (Houle, Mishara, & Chagnon, 2008; O’Neil, 2008).
Further analysis revealed that violent experiences have a significant impact on both males’ and females’ self-injurious behaviors, with the male and female students who have experienced verbal violence being more likely to use self-injurious behaviors, which is partly proved in existing research (Wedig & Nock, 2007). Besides, visual and sexual violence have a significant impact on female students’ self-injurious behaviors, with the female students who have experienced visual and sexual violence being more likely to use self-injurious behaviors, which is also in accord with previous research (Briere, 1992; Lynn & O’Neill, 1995). It is worthwhile to notice that in this study, although the impacts of sexual violence on female students’ self-injurious behaviors are significant at the level of p < .1, the regression coefficients are large (6.03, 7.87), whether or not the control variables are included in the model. This suggests that sexual violence experiences, such as sexual assault and sexual abuse, are much significantly associated with female self-injurious behaviors, but owing to the small number reported in the sample (only six female students reported sexual violent experiences, which was only about 1.4% of the total sample), the significance is lower.
Based on the above discussions, the following can be concluded: To some extent, there is a boy crisis in self-injurious behaviors among college students in China, and gender role conflicts are the important variable for explaining this crisis; in addition, verbal violence leads to self-injurious behaviors among both male and female college students, while visual and sexual violence lead to self-injurious behaviors among female students.
This study has some limitations with regard to the data. Due to the difficulties in tracing survey, only the cross-sectional data rather than the longitudinal data were used, which brings about a limitation in the causal analyses. The sample in this study includes only first- and second-year, female and male students from a university in western China. As it does not include high school students, the sample is somewhat limited. In terms of content, this study includes only gender role conflicts and violent experiences as the key factors associated with self-injurious behaviors, neglecting other possible associated factors, such as mood, psychological traits, personalities, depression, and anxiety.
In the future, other relevant variables should be added to the questionnaires, and the survey should include students from high school.
Footnotes
Acknowledgements
The authors would like to acknowledge the contribution of Janis Whitlock (research scientist at Cornell University) who generously sent her questionnaires (NSSI-AT) for our reference.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was jointly supported by a project sponsored by The China Ministry of Education of Humanities and Social Science project (Grant No. 13YJAZH118, questionnaires design), the Fundamental Research Funds for the Central Universities (Grant No. SK2013025, data collection), and the 985-3 Project of Xi’an Jiaotong University and Shaanxi Laboratory for Population and Development Research (data analysis and translation).