A Pilot Study Assessing Sexual Behavior as Self-Injury in College Students

Introduction

Suicide is now the second leading cause of death for individuals aged 10 to 24 years in the United States (Curtin & Heron, 2019). Suicidal behavior is difficult to predict, although one factor that contributes to suicide risk assessment is an individual’s participation in nonlethal self-injurious behaviors. Both nonsuicidal self-injury (NSSI), a type of direct self-harm that involves deliberate tissue destruction without suicidal intent (such as cutting or burning skin, hair pulling, hitting, or head banging), and indirect self-harm (such as drug use, risky sexual activity, or disordered eating) are related to an increased risk for suicidal behavior (Kiekens et al., 2018; Klonsky et al., 2013; Nock et al., 2006; St. Germain, & Hooley, 2012). A 2012 systematic review found the mean international lifetime prevalence of NSSI in adolescents (defined as ages 11–18) to be 18.0%, although differences in assessment methods and definitions of self-injurious behaviors complicated the comparison (Muehlenkamp et al., 2012).

Often considered only as a risk behavior, sexual activities with the potential for harm have been explored by some researchers as a type of indirect and/or direct self-harm. Examples of how sexual activity is proposed to be used as a form of self-injury include desired exposure to HIV or other sexually transmitted infections (Fredlund et al., 2020; Houck et al., 2008), exposure to violence at the hands of a partner, an experience of humiliation, or a reenactment of past abuse (Fredlund et al., 2020).

Engaging in sexual behavior as a way to self-harm differs from the more intense sexual activities of BDSM (standing for bondage and discipline, domination and submission, sadomasochism) in key ways. Although BDSM is also understudied, a recent scoping review found that it is best understood as a leisure or nonpathological sexual practice rather than a maladaptive or harmful practice (Brown et al., 2020). BDSM operates on constructed power differentials; however, any acts causing psychological or physical harm are agreed upon by all participants, and consent to the activity can be withdrawn by any participant at any time and the sexual activities stop (Brown et al., 2020). In addition, the experience of pain during BDSM is sometimes better described as stimulation (Jozifkova, 2013) as it is often interwoven with, or used to obtain, sexual pleasure.

As a distinct phenomenon, sexual activity as self-injury remains underexplored; therefore, the purpose of this study was to determine the feasibility of identifying sexual activity as self-injury in a U.S. college-based sample and to provide a preliminary examination of sexual activity as self-injury to inform future study on this topic.

Method

A cross-sectional descriptive pilot study was conducted. After receiving institutional review board (IRB) approval, recruitment materials were distributed through institutional email lists, institutional event boards, and social media. These multiple recruitment methods were used due to the emerging nature of this topic and the related goals of assessing for knowledge and willingness of participants to provide data on this topic. Individuals of any gender were eligible to participate if they attended any college or university in Texas, were 18 to 24 years old, were able to read and write in English, and were willing to answer questions regarding their mental health and sexual behavior. After providing informed consent, participants completed an anonymous online survey through a secure platform. An investigator-written tool was created based on a review of the literature as no standardized measures exist on this topic. Data collection was timed to coincide with the academic year, beginning late in the summer of 2020 and running through the end of spring of 2021. Study data were collected and managed using REDCap electronic data capture tools hosted at the researchers’ institution (Harris et al., 2009, 2019). After data were collected, descriptive statistics were calculated using SPSS. A qualitative descriptive approach was taken using targeted content analysis to assess and report broad themes across participant free-text responses (Sandelowski, 2000). Qualitative answers were read and coded independently by two reviewers, using inductive coding, to identify shared and salient themes.

Description of Survey

To assess for recognition of and attitudes toward sexual behavior as self-injury, participants were first asked whether they had ever heard of the concept of “sex as self-injury” and were then asked how they themselves would define it. The survey then asked participants a series of demographic and health history questions as well as questions on the topic of self-harm behaviors, sexual behaviors, and risk behaviors using both closed-ended and open-ended questions. To assess for a history of NSSI, participants were asked, “Have you every physically hurt yourself without the intent to die?” To assess for a history of sexual activity as self-injury, they were asked “Have you ever used sexual activities as a way to cause physical harm to yourself?” and “Have you ever used sexual activities as a way to cause psychological harm to yourself?” To assess for risky sexual activities engaged in to affect mood, participants were asked, “Have you ever used unsafe or risky sex to improve your mood or to relieve negative or anxious feelings?” Participants who answered affirmatively to any of these questions were then asked to provide the age of onset, frequency, and type of activity engaged in for each category. Participants who answered affirmatively to a history of sexual behavior to self-harm were also asked to provide the gender identity of any partner(s) involved and their motivations for engaging in the sexual behavior.

Results

A total of 50 participants completed the online survey. The mean age of the sample was 20 (SD = 1.5) years, with 68% identifying as female (n = 34), 20% as male (n = 13), and 12% (n = 6) as nonbinary. Nearly half (46%, n = 23) identified as Caucasian, followed by 30% (n = 15) Hispanic, Latinx, or Spanish origin; 26% (n = 13) Asian; 6% (n = 3) Black or African American; 4% (n = 2) Native American or Alaskan Native; and 2% (n = 1) North African or Middle Eastern racial/ethnic identity. Sexual orientation was indicated as heterosexual by 50% (n = 25), 26% (n = 13) as bisexual, 14% (n = 7) as gay or lesbian, and 10% (n = 5) preferred to self-describe.

A history of NSSI was reported by 34% (n = 17) of participants and 12% (n = 6) had attempted suicide. The most commonly reported lifetime mental health diagnoses were depressive disorders, anxiety disorders, and eating disorders, each of which was reported by 24% (n = 12) of participants. For those who reported any lifetime mental health diagnosis, 58% were diagnosed between the ages of 15 and 19. Over one third of participants (34%, n = 17) reported currently experiencing symptoms of a psychiatric disorder or were receiving treatment for a mental health disorder. When queried about risk behaviors, 48% (n = 24) reported engaging in partnered sexual activities while under the influence of drugs or alcohol. Childhood sexual abuse was reported by 15% (n = 8) of participants (five identifying as female, one as male, and one as nonbinary) and 4% (n = 2) were victims of sexual abuse as an adult (one identifying as female and one as nonbinary). One student reported having participated in exchange sex.

The majority of participants (74%, n = 37) indicated that they had not heard of the phrase/concept of “sex as self-injury”; however, when asked, “What does the phrase ‘sex as self-injury’ mean to you?” 88% of participants provided a definition. In defining their understanding of the phrase “sex as self-injury,” participants referenced both physical and psychological harm as well as solo and partnered activities. Within the definitions, consistent themes/concepts were identified such as engaging in sex so as to (a) inflict emotional and/or physical pain (“voluntarily participating in sexual activities with the intention to emotionally and physically hurt oneself”—19-year-old female); (b) punish/self-demean/humiliate/degrade (“deliberately engaging in dangerous sexual practices in order to impose on oneself a feeling of degradation or worthlessness”—22-year-old female; “Performing sex (oral, genital, anal) in a way that you know you will regret in the future and as a way to self-demean”—21-year-old female); (c) cope with stressful triggers, intrusive thoughts, or previous traumatic experiences (“Using sex as a way to cope/suppress negative thoughts”—19-year-old male); and (d) prove self-worth (“Having unwanted sex as a way to prove self-worth/value by hurting your own body”—21-year-old female). Participants often included words or phrases in their definitions such as “maybe,” “possibly,” and “I don’t know” or phrased their definition as a question: “Possibly the negative side effects and impact of sex on mental and physical health”—19-year-old female; “Engaging in unhealthy sexual practices as a way of coping with stress?”—21-year-old female.

Five participants reported they had used sexual activities to cause themselves physical harm. The gender identity of the participants in relation to the gender identity of their partners (when a partner was involved) was unique for each participant: female with a “gender fluid” partner, nonbinary with a “cis male” partner, nonbinary with a nonbinary partner, and nonbinary with a male partner. The types of sexual activities utilized were identified as “hard sex,” anal fisting, vaginal penetrative sex, and frequent sex with an abusive partner. One participant declined to identify the type of physical sexual behavior they engaged in. Intentions for engaging in this behavior were reported as follows: “causing me physical pain” (21-year-old nonbinary), “reliving past trauma & self harm” (23-year-old male), “show others that im [sic] vulnerable” (22-year-old nonbinary), “I wanted to kill myself” (23-year-old nonbinary), and wanting to please their partner (“I wanted to make the other person feel good, I thought it would build the relationship better than other things I could do and it was just pain, I can take pain. It was also kind of a rough day that day and I just wanted to feel good again”—19-year-old female). One participant indicated that they were still engaging in sexual behavior as a form of physical self-harm.

Four participants reported using sexual activities as a way to cause themselves psychological harm. Of the three participants who reported engaging in partnered activities to cause this harm, one identified as female, two as nonbinary, and all reported a male partner. Sexual activities used to cause psychological harm were listed as engaging in sex that they did not really desire, sex with an abusive partner, and autoerotic asphyxiation. One participant declined to disclose the type of behavior they engaged in. The participants reported their intentions for engaging in this behavior as follows: “Proving myself [sic] worth? Feeling needed?” (21-year-old female), “Reliving past trauma & self harm” (23-year-old male), and “I’m not worthy” (22-year-old nonbinary). One participant’s reported intent was unclear: “In the beginning, it was my intention for the first few months” (23-year-old nonbinary).

Interestingly, three of the participants who endorsed engaging in sexual activity as self-injury to cause physical harm also endorsed engaging in sexual activity as self-injury to cause psychological harm. One of these participants declined to disclose the specific sexual behaviors they engaged in for either form of self-harm. Another reported engaging in the same behaviors (penetrating sex with an emotionally and physically abusive partner) to cause both types of self-harm. The third reported engaging in different behaviors depending on the type of injury intended, engaging in anal fisting to cause physical harm versus autoerotic asphyxiation to cause psychological harm.

Five participants reported engaging in consensual sexual acts with the intent to feel pain or be injured. They identified engaging in “hard sex” and BDSM activities (including spanking and flogging) only. One participant reported the same activity (“hard sex”) with the intent to cause physical harm to themselves as they did to otherwise feel pain. One participant who reported engaging in BDSM with the intent to feel pain reported engaging in unwanted sexual activity to cause psychological harm, but did not report engaging in any sexual behaviors to cause physical harm. The remaining three participants who reported engaging in sexual activity to feel pain did not report engaging in any sexual activities to cause physical or psychological harm. These three participants reported that their intentions in using sexual activities to feel pain were to feel pleasure and please their partner, to obtain sexual satisfaction, and to feel an adrenaline rush.

When asked whether they had ever engaged in unsafe or risky sexual activity to improve their mood or to relieve negative or anxious feelings, 10 participants endorsed this item. These participants reported behaviors such as having unprotected sex (i.e., not using a condom, not using preexposure prophylaxis), having sex with multiple partners, having sex with partners who were not well-known to them, having sex in public, and masturbating until it became painful. The participant who reported masturbating until they felt pain did not clarify if pain was the intended outcome or an undesired effect.

Discussion

Findings from this pilot study suggest that college students in the United States have engaged in sexual behavior as a form of self-injury. Participants reported using sexual activity as a way to cause physical and/or psychological harm to themselves, supporting the evidence for sexual activity as a form of self-injury, including as a form of direct self-injury. Participants engaged in partnered and solo activities to cause harm with intentions that included desiring physical pain, reexperiencing past self-harm and/or trauma, demonstrating vulnerability, wanting to feel needed by or seeking to please others, exploring conflict about their self-worth, and experiencing suicidal thoughts. The number of responding participants who reported using sexual activities to cause physical harm to themselves is small, but comprised 12% of the study sample. This suggests that individuals who are using sexual activity as a way to self-injure are willing to discuss their behaviors with researchers and that internet-based recruitment and assessment is a practical method for conducting this research.

To ask individuals about sexual behaviors used to self-injure, it is likely not sufficient to ask broadly whether they have engaged in sexual activity as self-injury. The phrase “sex as self-injury” was not widely recognized and many participants were not confident in their interpretations of its meaning. It was apparent that people grasped the concept generally, but there was uncertainty in how to define it, suggesting that this phrase is too ambiguous to be used in screening without explanation. Ambiguity of nomenclature is a known limitation in the field of self-injury research and studies using behavioral checklists have been shown to lead to higher NSSI prevalence estimates compared with broader single-item assessments leading to possible over- or underestimation of such behaviors (Muehlenkamp et al., 2012). In addition, more nuanced and accurate data could be collected from asking specifically about sexual activity used to cause physical harm versus (or in addition to) psychological harm.

We included the question, “Have you ever engaged in consensual sexual activity with the intent to feel pain or be injured?” as a way of asking about sexual activity to self-injure without using self-injury terminology. We suspected that social stigma against self-injury might discourage some individuals from reporting sexual activity to self-injure or even prevent them from recognizing their activities as such. Instead, our findings identified that participants answered this question with reports of sexual behavior involving pain for sexual gratification. BDSM was not explicitly referenced in any of the responses on sexual activity as a way to cause physical harm to oneself, but was mentioned repeatedly when asked about consensual sexual activities to cause pain. This is in congruence with findings from a Swedish study investigating sex as a form of self-injury where only 6.5% of participants reported experiencing any positive feelings during the sexual acts used to cause physical harm (Fredlund et al., 2020). Our data suggest that specifying between pain for sexual gratification and sexual activity to cause harm that might include physical pain is key in separating self-injurious behaviors from typical BDSM behaviors.

Individuals who report using unsafe sexual activity to improve their mood or to relieve anxiety reported activities that would more closely align with sexual risk behaviors (e.g., unprotected sex, multiple sexual partners). Although sexual risk behaviors are sometimes considered to be a type of indirect self-harm (St. Germain & Hooley, 2012), they are notably different from using sexual activity as a form of self-injury in that the immediate intent of engaging in the sexual activity is not to cause injury. Sexual risk behaviors appear to exist across a continuum of intent for harm (or lack thereof) and the boundaries between impulsivity, recklessness, indirect self-injury, and direct self-injury require further examination.

Although this pilot study demonstrates that college students have engaged in sexual activity as a form of self-injury, limitations do exist. All data were collected via self-report in a cross-sectional online survey asking about sensitive topics, and as such response bias and recall bias may exist. In addition, this study utilized a small convenience sample of college students in a southwestern state. Therefore, study findings are likely influenced by participants’ high level of education and specific sociocultural backgrounds. This, and the fact that the population for this issue is currently unknown, limits the generalizability of these findings. Future study is needed to describe this phenomenon in other populations. Phenomenological exploration is needed to understand the trajectory of the behavior and how the emotional experience of using sexual behavior to self-injure is distinct from BDSM.

Conclusion

This study provides evidence for the use of sexual activity as self-injury, causing purposeful physical and psychological harm, among a sample of college students. Clinicians should consider that the presence of dangerous or risky sexual behaviors in their patients may signal the need for assessment of intent to self-injure. Similarly, clinicians should consider assessing for sexual activity with the potential for injury in patients who report other forms of self-injurious behavior. Clearly, the concept of sexual activity as self-injury requires further research that may be particularly suited to qualitative exploration to enhance conceptual clarity of this phenomenon.