32% of young females, and 22% of young males admitting to self-harm. studies also indicate that males who self-harm may also be at a greater risk of completing suicide. there does not appear to be a difference in motivation for self-harm in adolescent males and females. triggering factors such as low self-esteem and having friends and family members who self-harm are also common between both males and females. one limited study found that, among those young individuals who do self-harm, both genders are just as equally likely to use the method of skin-cutting. however, females who self-cut are more likely than males to explain their self-harm episode by saying that they had wanted to punish themselves. in new zealand, more females are hospitalized for intentional self-harm than males. females more commonly choose methods such as self-poisoning that generally are not fatal, but still serious enough to require hospitalization. elderly in a study of a district general hospital in the uk, 5.4% of all the hospital's self-harm cases were aged over 65. the male to female ratio was 2:3 although the self-harm rates for males and females over 65 in the local population were identical. over 90% had depressive conditions, and 63% had significant physical illness. under 10% of the patients gave a history of earlier self-harm, while both the repetition and suicide rates were very low, which could be explained by the absence of factors known to be associated with repetition, such as personality disorder and alcohol abuse. however, nice guidance on self-harm in the uk suggests that older people who self-harm are at a greater risk of completing suicide, with 1 in 5 older people who self-harm going on to end their life. a study completed in ireland showed that older irish adults have high rates of deliberate self-harm, but comparatively low rates of suicide. developing world only recently have attempts to improve health in the developing world concentrated on not only physical illness but also mental health. deliberate self-harm is common in the developing world. research into self-harm in the developing world is however still very limited although an important case study is that of sri lanka, which is a country exhibiting a high incidence of suicide and self-poisoning with agricultural pesticides or natural poisons. many people admitted for deliberate self-poisoning during a study by eddleston et al. were young and few expressed a desire to die, but death was relatively common in the young in these cases. the improvement of medical management of acute poisoning in the developing world is poor and improvements are required in order to reduce mortality. some of the causes of deliberate self-poisoning in sri lankan adolescents included bereavement and harsh discipline by parents. the coping mechanisms are being spread in local communities as people are surrounded by others who have previously deliberately harmed themselves or attempted suicide. one way of reducing self-harm would be to limit access to poisons; however many cases involve pesticides or yellow oleander seeds, and the reduction of access to these agents would be difficult. great potential for the reduction of self-harm lies in education and prevention, but limited resources in the developing world make these methods challenging. prison inmates deliberate self-harm is especially prevalent in prison populations. a proposed explanation for this is that prisons are often violent places, and prisoners who wish to avoid physical confrontations may resort to self-harm as a ruse, either to convince other prisoners that they are dangerously insane and resilient to pain or to obtain protection from the prison authorities. self-harm also occurs frequently in inmates who are placed in solitary confinement. history the results of self-flagellation, as part of an annual shia mourning ritual (muharram) mural of the mourning of the buddha, with various figures in ethnic costumes one of the consequences of the black death was practiced self-flogging. a ritual flagellation tool known as a zanjir, used in shia muharram observances self-harm was, and in some cases continues to be, a ritual practice in many cultures and religions. the maya priesthood performed auto-sacrifice by cutting and piercing their bodies in order to draw blood. a reference to the priests of baal "cutting themselves with blades until blood flowed" can be found in the hebrew bible. however, in judaism, such self-harm is forbidden under mosaic law. it occurred in ancient canaanite mourning rituals, as described in the ras shamra tablets. self-harm is practised in hinduism by the ascetics known as sadhus. in catholicism it is known as mortification of the flesh. some branches of islam mark the day of ashura, the commemoration of the martyrdom of imam hussein, with a ritual of self-flagellation, using chains and swords. dueling scars such as those acquired through academic fencing at certain traditional german universities are an early example of scarification in european society. sometimes, students who did not fence would scar themselves with razors in imitation. constance lytton, a prominent suffragette, used a stint in holloway prison during march 1909 to mutilate her body. her plan was to carve 'votes for women' from her breast to her cheek, so that it would always be visible. but after completing the v on her breast and ribs she requested sterile dressings to avoid blood poisoning, and her plan was aborted by the authorities. she wrote of this in her memoir prisons and prisoners. kikuyu girls cut each other's vulvas in the 1950s as a symbol of defiance, in the context of the campaign against female genital mutilation in colonial kenya. the movement came to be known as ngaitana ("i will circumcise myself"), because to avoid naming their friends the girls said they had cut themselves. historian lynn thomas described the episode as significant in the history of fgm because it made clear that its victims were also its perpetrators. classification the term "self-mutilation" occurred in a study by l. e. emerson in 1913 where he considered self-cutting a symbolic substitution for masturbation. the term reappeared in an article in 1935 and a book in 1938 when karl menninger refined his conceptual definitions of self-mutilation. his study on self-destructiveness differentiated between suicidal behaviors and self-mutilation. for menninger, self-mutilation was a non-fatal expression of an attenuated death wish and thus coined the term partial suicide. he began a classification system of six types: neurotic – nail-biters, pickers, extreme hair removal and unnecessary cosmetic surgery. religious – self-flagellants and others. puberty rites – hymen removal, circumcision or clitoral alteration. psychotic – eye or ear removal, genital self-mutilation and extreme amputation organic brain diseases – which allow repetitive head-banging, hand-biting, finger-fracturing or eye removal. conventional – nail-clipping, trimming of hair and shaving beards. pao (1969) differentiated between delicate (low lethality) and coarse (high lethality) self-mutilators who cut. the "delicate" cutters were young, multiple episodic of superficial cuts and generally had borderline personality disorder diagnosis. the "coarse" cutters were older and generally psychotic. ross and mckay (1979) categorized self-mutilators into nine groups: cutting, biting, abrading, severing, inserting, burning, ingesting or inhaling, hitting, and constricting. after the 1970s the focus of self-harm shifted from freudian psycho-sexual drives of the patients. walsh and rosen (1988) created four categories numbered by roman numerals i–iv, defining self-mutilation as rows ii, iii and iv. classification examples of behavior degree of physical damage psychological state social acceptability i ear-piercing, nail-biting, small tattoos, cosmetic surgery (not considered self-harm by the majority of the population) superficial to mild benign mostly accepted ii piercings, saber scars, ritualistic clan scarring, sailor and gang tattoos, minor wound-excoriation, trichotillomania mild to moderate benign to agitated subculture acceptance iii wrist- or body-cutting, self-inflicted cigarette burns and tattoos, major wound-excoriation mild to moderate psychic crisis accepted by some subgroups but not by the general population iv auto-castration, self-enucleation, amputation severe psychotic decompensation unacceptable favazza and rosenthal (1993) reviewed hundreds of studies and divided self-mutilation into two categories: culturally sanctioned self-mutilation and deviant self-mutilation. favazza also created two subcategories of sanctioned self-mutilations; rituals and practices. the rituals are mutilations repeated generationally and "reflect the traditions, symbolism, and beliefs of a society" (p. 226). practices are historically transient and cosmetic such as piercing of earlobes, nose, eyebrows as well as male circumcision while deviant self-mutilation is equivalent to self-harm. awareness and opposition there are many movements among the general self-harm community to make self-harm itself and treatment better known to mental health professionals, as well as the general public. for example, march 1 is designated as self-injury awareness day (siad) around the world. on this day, some people choose to be more open about their own self-harm, and awareness organizations make special efforts to raise awareness about self-harm. other animals self-harm in non-human mammals is a well-established but not widely known phenomenon. its study under zoo or laboratory conditions could lead to a better understanding of self-harm in human patients. zoo or laboratory rearing and isolation are important factors leading to increased susceptibility to self-harm in higher mammals, e.g., macaque monkeys. non-primate mammals are also known to mutilate themselves under laboratory conditions after administration of drugs. for example, pemoline, clonidine, amphetamine, and very high (toxic) doses of caffeine or theophylline are known to precipitate self-harm in lab animals. in dogs, canine obsessive-compulsive disorder can lead to self-inflicted injuries, for example canine lick granuloma. captive birds are sometimes known to engage in feather-plucking, causing damage to feathers that can range from feather shredding to the removal of most or all feathers within the bird's reach, or even the mutilation of skin or muscle tissue. breeders of show mice have noticed similar behaviors. one known as "barbering" involves a mouse obsessively grooming the whiskers and facial fur off of themselves and cage-mates. feather-plucking in a moluccan cockatoo lick granuloma from excessive licking