Children and adolescents who present to the emergency department (ED) for self-harm are at increased risk of subsequent visit to health services for sexual abuse or assault, a study has found.
“Presentation for self-harm during childhood and adolescence, in addition to being concerning for potential sexual abuse history, may be a marker of vulnerability for future sexual abuse or assault,” said the researchers, who used health administrative data to identify individuals with a first presentation for self-harm over a 10-year period (2013‒2022) in Ontario, Canada (population 16 million).
Using Cox proportional hazards modeling, the research team compared time to first presentation for sexual abuse or assault to that of individuals in a control group matched for age, sex, and area-level socioeconomic status.
A total of 139,233 individuals were included in the analysis. The 10-year cumulative incidence of presentation for sexual abuse for children and adolescents who had an initial presentation for self-harm was 9.06 percent (95 percent confidence interval [CI], 8.55‒9.57) compared to 1.26 percent (95 percent CI, 1.17‒1.36) for the control group (hazard ratio [HR], 8.32, 95 percent CI, 7.68‒9.02).
Such risk persisted even after adjusting for factors influencing vulnerability to sexual abuse (HR, 5.06, 95 percent CI, 4.53‒5.65). [Am J Psychiatry 2026;doi:10.1176/appi.ajp.20250691]
Similar results were observed for the outcome of sexual assault, with a cumulative incidence of 4.14 percent (95 percent CI, 3.76‒4.51) compared to 0.48 percent (95 percent CI, 0.41‒0.54) for the control group (fully adjusted HR, 6.44, 95 percent CI, 5.38‒7.71). Notably, a higher absolute risk was found for females in sex-stratified analyses.
“Given that only 6 percent to 27 percent of sexual abuse survivors disclose the abuse in healthcare settings, the true incidence could be much higher,” the researchers said. [TVA 2018; 19:251–265]
“While we could not definitively determine the timing of sexual abuse events, our evidence suggests that for a proportion of individuals, presentation for self-harm preceded sexual assault,” they added.
Factors
Previous studies have shown that vulnerability for sexual abuse is significantly more common among children and adolescents who are female, of younger age, have a history of sexual abuse, have mental health conditions, and belong to a lower socioeconomic status. [JAMA Netw Open 2020;3:e2012563; Child Abuse Negl 2011;35:3-17; Psychol Bull 2019;145:459-489; TVA 2019;20:67-80]
“Building on this literature, our evidence suggests that these risk factors are applicable to children and adolescents who have engaged in self-harm,” the researchers said.
“While we describe a relationship between ED presentation for self-harm and subsequent presentation for sexual abuse, further research is needed to investigate any underlying mechanisms,” they added.
Implications
Recommendations cannot yet be made until the current findings are replicated, but the research team noted potential clinical implications. Initially, a high-quality guideline must be established for self-harm management, suggesting safeguarding concerns be assessed without delay. [https://www.nice.org.uk/guidance/ng225]
“[W]e suggest that all children and adolescents presenting for self-harm be screened for previous, as well as ongoing, sexual abuse,” the researchers said.
“Screening may be justified given the high prevalence of sexual abuse in this population and the improved outcomes associated with early disclosure,” they added. [J Clin Child Adolesc Psychol 2007;36:260-266; J Child Sex Abus 2007;16:19-36]
Finally, mental healthcare must change from being a reactive system (crisis response) to being a proactive one (identifying and addressing root causes of poor mental health early) to more effectively address self-harm and sexual abuse, according to the researchers. [J Pediatr 2024;265:113479]