ORIGINAL ARTICLE

A Survey of Self-Mutilation From Forensic Medicine Viewpoint

Fakhredin Taghaddosinejad, MD,* Ardeshir Sheikhazadi, MD,* Asadolah Yaghmaei, MD,* Vida Vakili, MD,
Seyed Mehdi Saberi, MD, and Behnam Behnoush, MD*
Objectives: Currently little research exists examining self-mutilation (SM)
in samples of forensic referrals. The present study provides a comprehensive
review on the frequency, etiology, and morphologic characteristics of self-
inicted injuries in a sample of outpatients forensic referrals.
Methods: In a prospective cross-sectional study, during 3 years, we exam-
ined 9874 outpatients forensic referrals and found 1248 SM cases in
Ghouchan (an urban and suburban area of Iran).
Results: Based on forensic medical examinations, it was found that 12.6% of
all outpatients forensic referrals had engaged in SM behavior at sometime.
Males had signicantly higher rates of SM than females (76.9 vs. 23.1%,
respectively). The mean age was found to be signicantly lower in patients
with SM (23.6 8.5) than patients without SM (40.0 10.5) (P 0.001).
Rate of being single and unemployed was higher in the SM group (58.2,
56.1%, respectively) than in the group without SM (19.1, 22.8%, respec-
tively). Supercial cuts and scratches were found to be the most common
type of SM (79.5%), followed by bruises (10.8%), burns (3.4%), deep cuts
(3.2%), fractures (0.6%), and other miscellaneous injuries (2.5%). Upper
extremities including forearms, wrists, and arms opposite the dominant hand
were the most common areas of injury.
Conclusions: Nonsuicidal self-injury, the deliberate-direct destruction of
body tissue without suicidal intent is a relatively common event in forensic
referrals. It is very important to distinguish between this and other types from
forensic point of view. Forensic practitioners must be expert and trained for
this purpose.
Key Words: self-mutilation, self-injurious behavior, diagnosis, forensic
practice, Ghouchan, Iran
(Am J Forensic Med Pathol 2009;30: 313317)
S
elf-injurious behavior (SIB) refers to a broad class of behaviors
in which an individual directly and deliberately causes harm to
herself or himself. Such behavior can include nonsuicidal self-
injury, which refers to direct, deliberate destruction of ones own
body tissue in the absence of intent to die; or suicide attempts, which
refer to direct efforts to intentionally end ones own life. Histori-
cally, harming oneself without the intention of dying is not a new
phenomenon. Around 500 BC, Sophocles, the Greek dramatist,
wrote the tale of Oedipus Rex, who gouged out his eyes after
discovering he had slept with his mother. Vincent van Gogh engaged
in self-mutilation in 1888 by severing the lower part of his left ear
with a razor. A less well-known act of severe self-mutilation
involved Boston Corbett, the man who shot John Wilkes Booth. He
engaged in self-castration (several years before the shooting) after
reading several chapters in the book of Matthew.
1
Favazza and Rosenthal (1993) identify pathologic self-muti-
lation as the deliberate alteration or destruction of body tissue
without conscious suicidal intent. A common example of self-
mutilating behavior is cutting the skin with a knife or razor until pain
is felt or blood has been drawn. Burning the skin with an iron, or
more commonly with the ignited end of a cigarette, is also a form of
self-mutilation.
Self-mutilating behavior does exist within a variety of popu-
lations. For the purpose of accurate identication, 3 different types
of self-mutilation have been identied:
1. Supercial or moderate self-mutilation is seen in individuals
diagnosed with personality disorders (ie, borderline personality
disorder).
2. Stereotypic self-mutilation is often associated with mentally
delayed individuals.
3. Major self-mutilation, more rarely documented than the 2 previ-
ously mentioned categories, involves the amputation of the limbs
or genitals. This category is most commonly associated with
pathology.
2,3
Self-mutilation is a relatively common nding in psychiatric
and forensic practice and has been dened as deliberate harm to the
body without intending suicide. It includes a variety of different
acts, such as burning and cutting, and has been reported in 4% of the
adult population.
46
This behavior may result from serious under-
lying psychiatric illness or from attempts to secure some advantage
by pretending that the injuries were inicted by an assailant. In the
latter situation, cases may present themselves in both civil and
criminal jurisdictions and lead to requests for a medicolegal opinion
as to the likelihood of self-mutilation. Self-induced injuries in
forensic practice are also used to simulate criminal offenses and to
fraudulently obtain insurance payments. In these cases, appropriate
diagnosis is important from both a legal and psychiatric point of
view. Excluding inicted trauma may not be straightforward. It
seems self-mutilation has a high prevalence in forensic practice
within developing countries. We described 1284 cases involving
self-mutilation in Legal Medicine Organization (LMO) of Ghouchan
(north-east of Iran), during 3 years. Typical morphologic aspects and
combination of clinical signs in cases of self-mutilation are pre-
sented from forensic point of view to facilitate conrming the
diagnosis.
MATERIALS AND METHODS
Study Design
A prospective cross-sectional study design was used to de-
termine the frequency and morphologic characteristics of self-
inicted injuries in forensic referrals presenting to the LMO.
Setting and Population
The study was conducted in the LMO of Ghouchan, an urban
and suburban community in the north-east of Iran. Ghouchan with
about 186,000 residents (92,800 males and 93,200 females) is
located in Khorasan Razavi Province. All outpatients forensic
referrals from Ghouchan city over a 3-year period (January 2003
January 2006) were examined by one of the authors (A.Y.) from
Manuscript received October 15, 2007; accepted April 8, 2008.
From the *Department of Legal Medicine, Tehran University of Medical Sci-
ences, Tehran, Iran; and Legal Medicine Organization of Iran, Tehran, Iran.
Reprints: Ardeshir Sheikhazadi, MD, Department of Legal Medicine, Tehran
University of Medical Sciences, Poorsina St, Keshavarz Blvd, Tehran, Iran.
E-mail: ardeshirsheikhazadi@yahoo.com.
Copyright 2009 by Lippincott Williams & Wilkins
ISSN: 0195-7910/09/3004-0313
DOI: 10.1097/PAF.0b013e31819d217d
Am J Forensic Med Pathol Volume 30, Number 4, December 2009 www.amjforensicmedicine.com | 313
forensic viewpoint. All patients with self-inicted injuries were
identied. Information was collected on the age and sex of the
patient, the place and mechanism of injuries, the size, distribution of
the injuries, and other demographic characteristics. These groups of
patients as self-mutilators were referred directly to the teamworks
chief for evaluating and conrming the forensic diagnosis of delib-
erate self-injury and after approval of forensic diagnosis used by
taking a forensic medical history; physical examination, and a
structured interview were performed by forensic medicine special-
ists and psychiatrist (other authors) in cases of self-mutilation
included in the study.
Data Collection
Recording of data were performed by a full-time experienced
forensic practitioner who performed daily follow-up on all LMO
referrals. Data collection were performed by using standardized
study forms that included specic demographic and clinical infor-
mation, including the patients age, gender, marriage status, employ-
ment status, educational status, duration of education, diagnosis,
etiology, and mechanism of injury.
Data Analysis
Descriptive statistics were analyzed using SPSS 13.0 for Win-
dows (SPSS, Inc, Chicago, IL). Continuous variables are presented as
means with ranges. Categorical data are presented as frequency per-
centage of occurrence with 95% condence intervals (CI).
RESULTS
The study was conducted between January 2003 and January
of 2006. During the study period, 9874 outpatients forensic refer-
rals were seen in the Ghouchans LMO of which 1248 (12.6%) were
diagnosed as self-mutilated (SM) patients, including 960 (76.9%)
males and 288 (23.1%) females. The group without SM also was
including 8826 forensic referrals comprising 6130 (71.1%) males
and 2496 (28.9%) females. The male/female ratio in the SM group
was 3.3:1 and in the group without SM was 2.5:1 and there was no
signicant difference between the 2 groups. The age range of
self-mutilated patients in the study period was 11 to 48 years with an
overall mean age of 23.6 8.5 years. The mean age of male
self-injured patients was 23.2 10.7 years and mean age of the
female self-injured patients were 29.8 9.2 years. In comparison,
the age range of the group without SM in the study period was 4 to
72 years with an overall mean age of 40.0 10.5 years. The mean
age of male patients without SM was 39.8 11.8 years and mean
age of the female patients without SM were 41.8 10.2 years. The
mean age was found to be signicantly lower in patients with SM
(23.6 8.5) than patients without SM (40.0 10.5) (z 6.08,
P 0.001).
Rate of being single and unemployed was higher in the SM
group (58.2, 56.1%, respectively) than in the group without SM
(19.1, 22.8%, respectively) (
2
23.24, df 2, P 0.001 and

2
13.63, df 3, P 0.003, respectively). Education status (
2

4.96, df 3, P 0.18) and duration of education did not differ

signicantly between groups (z 1.82, P 0.07). Sociodemo-
graphic characteristics of outpatients forensic referrals are showed
in Table 1.
Rate of the presence of previous scarication was higher in
the SM group (n 389, 31.2%) than in the group without SM
(n 336, 3.9%) (P 0.001). Among the 1248 self-mutilators, 59
(4.7%) reported 3 or more episodes of self-mutilation. There
were no demographic differences between infrequent mutilators
and frequent mutilators. In 749 cases (60%) of SM group there
was simultaneously non-self-induced traumatic injuries in other
parts of their bodies.
Although seasonal variation did not vary signicantly be-
tween groups, there was a higher seasonal variation in frequency of
self-mutilation among forensic referrals. There was an increase in
self-mutilation frequency in the spring (490 cases, 39.3%) and
summer (404 cases, 32.4%). Two hundred sixty-one cases (20.9%)
referred in fall and only 93 cases (7.4%) in winter.
Of all self-inicted injuries, 992 (79.5%; 95% CI, 78.081.0)
included supercial cuts and/or scratches. Bruises (n 135; 10.8%)
were the second most common lesions. Other self-inicted injuries
included burns (n 42; 3.4%), deeper cuts that needed sutures (n
40; 3.2%), fractures (n 8; 0.6%) and other miscellaneous injuries
(n 31; 2.5%). Anatomic locations of self-inicted injuries, in-
cluded upper extremities (n 1008; 80.8%), trunk (n 112; 9.0%),
TABLE 1. Sociodemographic Characteristics of Outpatients Forensic Referrals to Ghouchans LMO
From January 2003 to January 2006
No Self-Mutilation Self-Mutilation

2
SD P N 8826 % N 1248 %
Age (mean SD) 40.0 10.5 23.6 8.5 z 6.083 0.001
Marital status 23.24 2 0.001
Married 6729 76.2 462 37.0
Divorced 412 4.7 60 4.8
Single 1685 19.1 726 58.2
Employment status 13.63 3 0.003
Not working 2012 22.8 700 56.1
Working 3396 38.5 207 16.6
Part time 1412 16.0 161 12.9
Housewife 2006 22.7 180 14.4
Education 4.96 3 0.18
Elementary 3265 37.0 508 40.7
High school (68 grades) 1324 15.0 324 26.0
High school (911 grades) 2925 33.1 342 27.4
University 1312 14.9 74 5.9
Duration of education (mean SD) 9.9 3.8 8.7 3.2 z 1.822 0.07
Taghaddosinejad et al Am J Forensic Med Pathol Volume 30, Number 4, December 2009
314 | www.amjforensicmedicine.com 2009 Lippincott Williams & Wilkins
face (n 59; 4.7%), lower extremities (n 56; 4.5%), and skull
(n 13; 1.0%). Upper extremities were the most common site of
self-inicted injuries. Forearms, wrists, and arms opposite the dom-
inant hand were common areas for injury. A breakdown of types and
locations of self-inicted injuries is presented in Table 2.
Depending on the underlying motives, there were generally 3
main categories of self-inicted injuries:
1. Simulated offenses (alleged assaults with a scufe, ctitious
sexual offenses, or feigned robbery). Underlying motive of 886
cases (71.0%) was to simulate offenses. Alleged assaults follow-
ing scufes were the most common cause of referrals, and most
of those were males. The second most common group was young
females and their motive was ctitious sexual offenses. Other
miscellaneous motives in this category were rare.
2. Self-mutilation for the purpose of insurance fraud (n 339;
27.2%). Most of these were male and there was a signicant
difference between males and females within this category (P
0.001).
3. Self-inicted bodily harm or self-mutilation among soldiers and
prisoners (n 23; 1.8%). All of them were male.
The morphologic characteristics of self-inicted injuries in
groups mentioned above will be discussed.
DISCUSSION
In the present study, 12.6% (13.5% for males, 10.3% for
female) of 9874 forensic referral subjects were diagnosed as self-
mutilation. This percentage is signicantly higher than the incidence
of SM among the general population, which has been reported in
about 4% of the adult population in many studies.
411
This nding
is consistent with the idea that the frequency of self-mutilation
behavior can be higher in forensic samples than the general popu-
lation. The explanation is that SIB may share an etiology originated
from illegal gain in forensic referrals.
Although self-mutilation usually has a higher prevalence
among females in the general population,
1218
we found a higher
prevalence of this behavior among males in forensic referrals. The
explanation is that forensic referrals include a high proportion of the
males in our community and also they may be taking a risk to
achieve a goal more than females.
One of the important ndings of the present study was that the
mean age was found to be lower in patients with SM than in patients
without SM and age was one of the predictors of SM in logistic
regression model. In a general population survey, Briere and Gil
(1998)
6
found that one of the variables having a relationship with
SM was younger age.
There were signicant differences between groups in terms of
marriage and employment conditions. To be single and also unem-
ployed are conditions more common in the SM group than in
patients without SM. These ndings suggest that singles and unem-
ployed patients might have more reasons to seek a gain through
self-mutilation.
Rate of the presence of previous scarication was higher in
the SM group and in the majority of cases there were simultaneously
non-self-induced traumatic injuries in other parts of their bodies.
These ndings suggest that the SM group patients might have more
experiences of previous self-injury and they may self-harm to
exaggerate nonfatal offenses against them.
Although there was an increase in self-mutilation frequency
in the spring and summer, seasonal variation did not differ signi-
cantly between groups. It seems that is partly due to a total increase
in the frequency of forensic referrals in the rst half-year (Persians
calendar) in Iran. According to annual report of Irans LMO, there
is an increase in total frequency of outpatients forensic referrals in
the spring and summer in Iran.
19
The means by which people harm themselves are diverse and
personal. However, this study suggests that for men, as well as for
women, cutting is the most prevalent form of self-injury among
outpatients forensic referrals. More than 80% of all the SM patients
we examined had cut themselves, although the majority of them
were supercial cuts. As the earlier studies were shown, among
various forms of self-mutilation, self-cutting is the most convenient
form used by adolescents.
20
Despite this, there are also differences
between the ways in which men and women self-harm. Men tend to
injure themselves more severely than women and have less concern
about bodily disgurement.
21
They are also more likely to engage in
public and violent self-harm, such as punching themselves or a wall,
breaking bones, or in dangerous behavior as a means of self-harm.
In the present study, self-cutters were the predominant group among
outpatients forensic self-mutilators with a peak incidence from 16-
to 25-year-old men and 26- to 35-year-old women. The way of
cutting was usually light and supercial cutting without harming the
arteries. Some self-mutilations and self-cuttings were repetitive
behaviors.
Self-injury was most commonly associated with cutting,
which had involved making cuts or scratches on the body. Cutting
can be done with any sharp object, including knives, needles, razor
blades, or even ngernails. Most frequently, forearms, wrists, and
arms opposite the dominant hand were common areas for injury.
Front of the torso, legs, and forehead were the other targets of
self-injury because these areas can be easily reached but any area of
the body may be subjected to self-injury.
People who injure themselves often try to keep their behavior
secret. There is no one single or simple cause of self-injury,
however, in forensic patients trying to access a gain is the major
cause of these behaviors. The underlying motives in SM group of
forensic referrals were in 1 of the 3 main categories as described
below.
TABLE 2. Breakdown of Types and Locations of
Self-Inflicted Injuries in Forensic Outpatients of Ghouchans
LMO From January 2003 to January 2006
Total injuries 1248
Sex
Males 960 (76.9%)
Females 288 (23.15)
Mechanism of injury
Incised trauma 1032 (82.7%)
Blunt trauma 155 (12.4%)
Burns (hot objects) 42 (3.4%)
Other 19 (1.5%)
Anatomical location
Upper extremity 1008 (80.8%)
Trunk 112 (9.0%)
Face 59 (4.7%)
Lower extremity 56 (4.5%)
Skull 13 (1.0%)
Diagnoses
Supercial cuts and or scratches 992 (79.5%)
Bruises 135 (10.8%)
Burns 42 (3.4%)
Deep cuts 40 (3.2%)
Fractures 8 (0.6%)
Other miscellaneous injuries 31 (2.5%)
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2009 Lippincott Williams & Wilkins www.amjforensicmedicine.com | 315
Simulation of Criminal Offenses
Depending on the motive, the group of simulated criminal
offenses comprised several different categories of cases:
1. False allegation of an assault for the purpose of criminal suit.
2. Self-damage to divert attention from previous misconduct (eg,
embezzlement).
3. Simulation of a sexual assault to divert attention from earlier
unlawful love affair and to reach a mandatory matrimony.
4. Self-damage to simulate a situation of defense or to cover up an
offense committed by themselves against another person.
5. Fictitious offense with self-inicted injury to take revenge on
persons or institutions.
6. Self-induced injuries to pretend that the informant was the victim
of an offense with a robbery background.
In our country, punishment of rape is gallows (wooden frame
from which a condemned person is executed by hanging). Differ-
ential diagnosis between rape and ctitious sexual offenses is
essential and critically important. In ctitious sexual offenses, it is
paramount to analyze the extragenital injuries with regard to their
type, localization, and distribution. The wound pattern is often in
obvious contrast to the dramatic story told about the course of
events. Characteristic features are cuts or abrasions of minor inten-
sity, usually with a multitude of individual lesions. Even curved
body surfaces show skin lesions of equally shallow depth. The
typically uniform, grouped, and often parallel arrangement is
strangely contradictory to the dynamics of the alleged ght.
3
Irreg-
ularities, as they are expected after a real assault, are often miss-
ing.
3,22,23
Occasionally pattern-like and symbolic pictures are
seen.
24
The injuries usually heal without complications even when
left untreated.
As instruments pointed or sharp objects (knives, razor blades,
nail scissors, broken glass, etc) or the persons own ngernails are
used.
25
Easily reachable body regions (wrists, forearms, arms, fore-
head, cheeks, thoracic, and abdominal skin, neck and legs) are
preferred; especially sensitive regions like eyes, lips, and nipples as
well as the genital regions themselves are mostly omitted.
3
Both
sides of the body may be injured almost symmetrically, although
sometimes the side opposite the dominant hand may be more
affected. On the back, the injured parts are determined by the reach
of the individuals hands.
24,25
In rare cases, injuries may even be
inicted by a helper.
Discrepancies between the description of the offense and the
objective ndings can support the suspicion of self-iniction. Spe-
cial attention should be paid to inconsistencies between the damage
on the clothing and the injuries. Occasionally, the informants inict
excoriations on themselves by rubbing their skin against rough
surfaces or blunt objects.
25
Self-inicted hematomas as well as deep
stab or cut wounds are also seen in rare cases.
2426
Most women simulating a sexual assault are young. Possible
motives for reporting a false offense may include conicts with the
lover, misleading in marriage as a goal programming, imminent
separation from the partner, and problems with the parents. Multiple
false reports by one and the same person are not uncommon. In cases
of repeated self-iniction of injuries scars may point to former
incidents.
Not only sexual offenses, but also attacks and assaults for
other motives can be simulated. Sometimes the informants inict
cuts and stabs, rarely also injuries by blunt force, on themselves to
support their fabricated story of the event. The phenomenon as such
is not new. In 1910, already Strassmann reported on the features of
self-inicted injuries affected to feign an assault by another party.
3
In the 1960, Holzer published a detailed article on the solution of
cases involving ctitious assaults.
3
In recent years, numerous case
reports have been written on this subject.
3,24
A signicant sign of self-iniction is the inconsistency be-
tween the damage on the clothing and the injury pattern on 1 hand
and the story told about the incident on the other. The pattern of
ndings often resembles what is seen in ctitious sexual offenses,
although untypical manifestations are not uncommon. Sometimes
persons claiming to have been assaulted are found to be completely
unharmed, even though they pretend to have been severely trauma-
tized and to have been unconscious for a prolonged period.
3
In
members of medical professions, the application of medical knowl-
edge and special skills must be kept in mind. In the group of feigned
assaults (without sexual motivation) males are also frequently rep-
resented as alleged victims.
3,24
Self-Mutilation for the Purpose of Insurance Fraud
The medicolegal differentiation between injuries due to acci-
dents and intentionally self-inicted harm is very important. Some
of the forensic referrals are the fraudulent persons who wish to have
insurance compensation by simulating self-inicted harms as inju-
ries due to accidents. The common feature of these cases is an
accident that is simulated to fraudulently obtain insurance benets.
The criteria suggesting intentional self-iniction was dened
by Taylor cited by Lochte
27
Supercial character and harmlessness
of the wounds as well as localization on body sites where the effect
can be safely predicted, localization of the injuries on the side
opposite the dominant hand, and presence of a multitude of individ-
ual lesions are the criteria that suggest intentional self-iniction.
Mostly the self-damage consists of mutilating a peripheral part of
the body (nger or hand). This is usually done by using sharp
instruments such as axes, choppers, cutters, or motor saws. In rare
cases objects causing blunt traumatization are also used.
Intentionally inicted injuries from axe blows are often prox-
imal amputations of a single nger being severed at a right angle to
its longitudinal axis. In contrast, most real accidents involve con-
comitant injuries of the adjoining ngers as well. An oblique and
distal course with incomplete severance is more indicative of an
accident.
28
Proximal, complete severance of the index nger without
involvement of the neighboring ngers is highly suspect of self-
mutilation; although this type of severance is also possible when the
nger is placed in a so-called execution position. Finger amputa-
tion is also one of the legal punishments in Islamic Punishment Law.
When investigating a questionable accident suspected of attempted
insurance fraud, all available sources should be used (photographs,
x-rays, operation report, physical examination, biologic traces).
Moreover, the local circumstances at the scene, the properties of the
instrument used for inicting the injury, the distribution of the blood
traces, and the whereabouts of the amputation should be taken into
account.
Self-Inflicted Bodily Harm or Self-Mutilation Among
Soldiers and Prisoners
During war, the number of self-inicted injuries with rearms
was naturally and disproportionately high, but amputation by cutting
off ngers was also seen in soldiers and persons during the con-
scription. In some of these cases, several parallel strokes had to be
performed before the nger was severed.
Autoaggressive behavior also is a common problem with
detainees in police custody, in pretrial detention and in prison.
Self-iniction of cuts (especially on the forearms) is particularly
frequent by using sharp-edged objects such as knives, razor blades,
pieces of metal or broken glass. Another method of self-damage
consists of swallowing foreign (metal) bodies, which are sometimes
not excreted naturally because of their size and shape and have to be
Taghaddosinejad et al Am J Forensic Med Pathol Volume 30, Number 4, December 2009
316 | www.amjforensicmedicine.com 2009 Lippincott Williams & Wilkins
removed by surgery. In a broader sense simulation; aggravation and
prolongation of illnesses, are also forms of self-harm.
3
CONCLUSIONS
Differences in clinical features between self-inicted, acci-
dental, and intentional assault injuries in a forensic medicine center
were studied using the forensic medical history, physical examina-
tion, and a structured interview, performed by forensic medicine
specialists and a psychiatrist. Nonsuicidal self-injury the deliberate-
direct destruction of body tissue without conscious suicidal intent is
a relatively common occurrence in forensic referrals. Distinguishing
between them is very important and forensic practitioners must be
trained for this purpose. Legal Medicine Organization of Iran with
about 1.5 million forensic referrals per year is an appropriate eld
for such research and training.
2931
ACKNOWLEDGMENTS
The authors thank the Legal Medicine Organizations chief,
their employees, and all participants who assisted with this survey.
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