How Some Typical Male Behaviors Can Mask Mental Health Problems in Teenage Boys

 When parents find out their teen engages in self-harm, known by mental health clinicians and professionals as non-suicidal self-injury (NSSI), their first reaction is often a mixture of confusion and disbelief. Those emotions are often followed by sadness, self-blame, and the question “Does this mean my teen wants to kill themselves?” Then they research what self-harm is, and find this definition provided by the American Psychological Association (APA):

“The condition – clinically known as non-suicidal self-injury or NSSI — is characterized by deliberate self-inflicted harm that isn’t intended to be suicidal. People who self-harm may carve or cut their skin, burn themselves, bang or punch objects or themselves, embed objects under their skin, or engage in myriad other behaviors that are intended to cause themselves pain but not end their lives.”

Parents learn that while behaviors like self-harm, cutting, self-mutilation, and other forms of self-injury increase the risk of subsequent suicide attempts – especially in males – teens most often engage in self-harm for the following two reasons:

1. To escape or process negative emotions.

Around 74% of teens say they engage in NSSI to:

• Escape negative emotions
• Induce positive emotions
• Punish themselves

2. To signal their emotions to parents, friends, or others.

Around 46% say they engage in NSSI to:

• Communicate their sadness, anger, or despair
• Change the behavior of others
• Punish others for perceived wrongs

Then, when they do more research, they read the following statistics. These numbers are from a nationwide survey that collected data from over sixty-thousand teenagers (the second link, above):

• 17% of adolescents said they’d engaged in self-harm
• 11% of males said they’d engaged in self-harm
• 24% of females said they’d engaged in self-harm

Studies like that create the narrative that adolescent girls are more likely to engage in self-harm or NSSI than adolescent boys. That’s our first answer to the question posed in the title of this article.

Parents miss signs of self-harm in adolescent males because, among people who know about self-harm, the general consensus is that girls engage in self-harm more often than boys.

Self-Harm in Male Adolescents: How and Why We Miss It

An article published by the American Psychological Association (APA) contains a paragraph directly relevant to this discussion:

“Young white females tend to represent the public’s perception of NSSI, but at least 35 percent and as many as half of self-injurers may be male, studies also show. The number is uncertain in part because males present differently from females and may, therefore, be underreported…females are more likely to engage in self-cutting…while males are more prone to deliberately bruising themselves, hurting themselves while taking a substance, or having others hurt them.”

That’s one piece of the puzzle of why parents – and mental health professionals, for that matter – often miss the signs of self-harm in adolescent males. Another piece is the fact that most adolescents who engage in self-harm also have a separate, but related, mental health disorder. Studies show that among adolescents who self-harm, these mental health disorders are common:

• Depression/mood disorders
• Anxiety/anxiety-related disorders
• Substance use disorders (SUD)
• Eating disorders
• Personality disorders
• Post-traumatic stress disorder (PTSD)

The disorder that causes the most misunderstanding is depression. Personality disorders, for instance, are associated with the highest rates of self-harm. But they also have symptoms that are prominent, difficult to miss, and difficult – for mental health professionals in particular – to confuse with other mental health disorders. The same is true, to a lesser extent, with the other disorders most often diagnosed alongside NSSI. Their symptoms are specific, and, for an experienced mental health professional, diagnosis is relatively straightforward.

However, depression in adolescent boys often looks different than depression in adolescent girls. The same is true for self-harming behaviors and methods of self-harming behaviors, as indicated in the article we quote above.

Let’s look at how depression and self-harm differ in adolescent boys as compared to girls, starting with depression.

Depression in Boys

When therapists diagnose mental health disorders, they use the Diagnostic and Statistical Manual of Mental Disorders (DSM-V). The DSM, for the most part, differentiates between how the symptoms of depression appear in boys and girls. That’s not always a problem, because gender-specific criteria for mood disorders can lead to bias. In some cases, it could lead to institutional norms that skew treatment, affect insurance coverage, and negatively impact the health and well-being of one gender over another.

However, in the case of depression and boys, it means mental health professionals – and parents – need to understand the gender differences in how depression can manifest.

Research shows teenage girls often show symptoms more commonly associated with depression such as sadness, crying, guilt, and changes in appetite, depression in teenage boys is likely to appear in the following ways:

• Anger
• Irritability
• Difficulty concentrating
• Sleeplessness
• Suicide attempts

A recent study identified three gender norms common to males that can degrade their overall mental health and wellbeing – and can increase risk of depression:

The Self-Reliant Male

This covers males who believe they don’t need help from anyone for anything. Ever. Research shows males who embrace this norm avoid seeking help for emotional problems.

The Ladies Man

This covers men driven to feel attractive to more than one woman at a time. Research shows males who embrace this norm have difficulty establishing meaningful relationships.

The Fighter

This norm refers to the male who is willing to fight if his masculinity is questioned in any way at all. Research shows males who embrace this norm have difficulty regulating their emotions and may act out violently when under stress.

Men – including adolescent teens – who consciously on unconsciously conform to one or all three of these gender norms are vulnerable to developing various mental health disorders, including depression. Which, in turn, increases their risk of engaging in self-harming behavior.

Now let’s take a look at the most common risk factors and warning signs for self-harming behavior. As we list these risk factors and warning signs, we’ll include the factors specific to adolescent males that parents might miss.

Self-Harm in Male Adolescents: Risk Factors and Warning Signs

Risk factors are the default conditions in an individual’s life that are associated with an increased likelihood of developing a specific mental health disorder. The APA indicates the following factors as significantly associated with increased risk of NSSI:

• Presence of mental health disorders
• Previous instances of self-harm
• Previous suicide attempts
• Suicidal ideation
• Early trauma, a.k.a. adverse childhood experiences, or ACEs
• History of psychiatric disorders, self-harm, or suicidal behavior in family
• History of suicide in the family
• Victimization through traditional or cyberbullying
• Identifying as non-binary, questioning, and/or LGBTQI

We’ll combine the information we present above with these risk factors, and add another for male adolescents. If parents know their teenage boy displays behavior associated with the three male gender norms we describe above – The Self-Reliant Male, The Ladies Man, and/or The Fighter – that means they’re at increased risk of depression. Which, therefore, means they’re at increased risk of self-harming behavior.

Now let’s take a look at the most common warning signs of self-harming behavior.

Self-Harm in Teens: Top Warning Signs

• Wearing long sleeves or pants during warm weather
• Presence of unexplained cuts, scratches, bruises, or burns anywhere on the body
• Peers who engage in NSSI
• Missing patches of hair, including eyelashes or eyebrows
• Presence of sharp objects hidden in the bedroom, backpack, clothes, or car
• Isolating in the bedroom with the door locked
• Presence of unexplained wounds or scars anywhere on the body
• Presence of sharp objects with blood on them

This is where identifying self-harm in boys can get complicated. When unexplained cuts or bruises appear on their body, boys may explain them with reasons associated with macho male culture, such as:

• I got in a fight
• That’s from football practice
• We were messing with our pocketknives and I accidentally got cut
• I wrecked my bike
• I fell off my skateboard

Granted, girls get in fights, play contact sports, have pocketknives, and ride bikes and skateboards. However – and we know we’re generalizing without data here – boys are often more intense and extreme in the way they go about these behaviors and activities, as compared to girls. It’s a function of traditional maleness and testosterone. Boys can use this increased intensity – and the common injuries associated with this intensity – to explain away injuries they cause themselves.

And parents are likely to believe them.

In addition, boys engage in the following behaviors more often than girls:

• Tattooing
• Extreme piercings
• Body modifications
• Self-mutilation, i.e. branding or scarring

Let’s be clear, here. Tattoos, piercings, body modifications, and even some branding and scarring are not themselves, alone, acts of self-harm associated with mental health issues and they do not themselves, alone, qualify as NSSI as defined in the strictest clinical sense.

That’s exactly why boys who do engage in these behaviors in order to regulate overwhelming emotion or communicate emotional distress often fly under the radar. No one identifies these behaviors as self-harm warning signs and when asked, boys will say “It’s just a tattoo/piercing/brand/scar I think looks cool.”

However, when parents see these signs in teenage boys and the risk factors listed above are also present, these behaviors should be considered red flags. That means it’s time to take action.

What Parents Can Do

Here are three steps to take if your teen shows the warning signs above – the common ones and the male-specific ones – and the common risk factors are also present:

1. Talk to him. Find the time for a serious conversation about what you see. Stay calm and stay rational. At the same time, make sure your son knows you love him unconditionally and support him no matter what.
2. Schedule a professional psychiatric assessment. A trained and licensed mental health professional can determine if there are risk factors present. They can identify any undiagnosed emotional, substance use, or other mental health disorder. You can find a qualified professional in your area with this psychiatrist finder provided by the American Academy of Child and Adolescent Psychiatry.
3. Get professional support. If a psychiatric assessment indicates your sone needs professional support, then discuss the options with your family. Outpatient therapy, partial hospitalization, intensive outpatient therapy, or residential treatment programs are potential options for treatment and support. The assessing professional can determine the level of need and help you develop a plan of action.

Evidence shows that when a teenager with a mental health disorder gets the treatment they need sooner rather than later, long-term outcomes improve. A study published recently provides evidence that dialectical behavioral therapy (DBT) is an effective, evidence-based treatment for teens who engage in self-harm. To learn more, click that link or read this article:

New Study Confirms DBT Effective Treatment for Teens who Self-Harm

Self-Harming Behavior: Resources for Parents and Teens

Here’s a list of resources anyone – parent, teen, friend, other relative, or concerned party – can use right now to start the healing process:

• Parents can find a qualified professional in your area with this psychiatrist finder provided by the American Academy of Child and Adolescent Psychiatry.
• Teens who need help can call or text the following numbers:
  • The National Suicide Prevention Lifeline (24/7/365): 1-800-273-8255
  • The Trevor Project Phone (24/7/365): 1-866-488-7386
  • Trevor Project Text (7 days/wk, 6am-am ET, 3am-10pm PT): Text START to 678678
  • The Trevor Project Chat: CLICK HERE
  • The Crisis Text Line (24/7/365): Text CONNECT to 741741
  • The Youth Yellow Pages TEEN LINE (6pm-10pm PT) 310-855-4673
  • The Youth Yellow Pages TEXT: Text TEEN to 839863