“Male dominance – and with it the prevalence of the male physique – was cemented into medication’s very foundations… Girls had been marked by their anatomical distinction from males, and medically outlined as defective, faulty, poor.”
— Elinor Cleghorn (2021, pp. 6-7)
The historical past of medication is marked by an entrenched misogyny that has formed what’s studied, how it’s studied, and what’s taken to depend as reputable data. Organic fashions have overwhelmingly centred male physiology, male life programs, and male assumptions about danger. Girls’s experiences have typically been handled as deviations from this norm, quite than as phenomena worthy of examine in their very own proper. This bias is especially stark in relation to girls in midlife. Cultural narratives often painting menopausal girls as shedding magnificence, worth, and sexuality, whereas healthcare disparities persist by medical bias and a relative absence of targeted analysis (Gibbons, 2025a).
In opposition to this background, this new UK examine of self-harm and suicide in girls aged 40–59 may be very welcome. It addresses an under-examined group utilizing sturdy, long-term knowledge.
Girls, notably girls in midlife, typically should not the main target of well being analysis. This examine seeks to discover self-harm and suicide in girls aged 40-59 years.
Strategies
The examine attracts on routinely collected hospital knowledge from three English cities and consists of greater than 14,000 hospital shows for self-harm by girls aged 40–59 between 2003 and 2016, with mortality follow-up by nationwide Workplace for Nationwide Statistics data to the tip of 2019. The authors study charges of hospital-presenting self-harm, strategies used, clinician-recorded precipitants, scientific responses together with psychosocial evaluation and psychiatric admission, repetition of self-harm, and suicide mortality. A comparability group of youthful girls aged 25–39 is included, and variations inside midlife are explored utilizing five-year age bands.
Outcomes
The authors report a number of key findings. Charges of hospital-presenting self-harm in girls aged 40–59 had been excessive however decrease than in youthful girls, and self-harm charges declined steadily throughout midlife, with the bottom charges in girls aged 55–59, whereas remaining comparatively steady over time total. In contrast with youthful girls, girls in midlife had been extra prone to report monetary difficulties, alcohol issues, bodily well being issues, psychological well being issues, and bereavement as precipitants of self-harm, with bodily well being issues and bereavement growing with age inside midlife and alcohol involvement frequent throughout all age bands. Regardless of declining self-harm shows and lowered longer-term repetition in older midlife girls, scientific responses turned extra intensive with age, with greater charges of psychosocial evaluation and psychiatric inpatient admission. All-cause mortality elevated markedly throughout midlife, and suicide mortality was greater than twice as excessive within the oldest midlife girls in contrast with the youngest, though absolutely the variety of suicide deaths was small.
Suicide mortality was greater than twice as excessive within the oldest midlife girls in contrast with the youngest girls.
Conclusions
The authors conclude that girls in midlife should not a homogeneous group, that vulnerabilities and care wants change throughout this era, and that higher consideration to alcohol use, monetary stressors, bodily and psychological well being issues, and age-related social transitions could also be necessary for scientific formulation and security planning.
Girls in midlife should not a homogenous group; we have to discover what elements contribute to the elevated charges of suicide on this inhabitants.
Strengths and limitations
To grasp what this examine actually tells us, we have to do one thing that suicide analysis nonetheless struggles to do, and that’s not completed clearly within the authors’ interpretation: we have to separate self-harm from suicide, and study every rigorously quite than assuming they’re merely completely different expressions of the identical downside. One of many enduring difficulties in suicide analysis is the tendency to break down self-harm and suicide right into a single continuum, regardless of a long time of proof that they’re associated however distinct phenomena (Gibbons 2024a, 2024b; Gibbons, 2025a). Self-harm, which is frequent, and suicide, which is uncommon, are sometimes handled as interchangeable, an assumption that obscures their completely different capabilities, motivations, and dynamics, and might confound each analysis and scientific observe (Gibbons, 2025b).
Self-harm typically capabilities as a method of dealing with misery: regulating overwhelming have an effect on, speaking ache, or sustaining connection (Gibbons, 2024a). Suicide, in contrast, extra typically includes withdrawal from relationship and a transfer towards psychic finality, an try to flee insufferable psychological ache quite than to sign it (Shneidman, 1993). Though self-harm is statistically related to later suicide (Geulayov et al., 2019; Hawton et al., 2015; Tidemalm et al., 2015), this doesn’t imply the 2 are psychologically equal. They could share vulnerabilities, equivalent to lack of mentalisation or collapse of symbolic processing, whereas remaining clinically and phenomenologically completely different acts (Gibbons, 2024).
When self-harm is examined in its personal proper on this examine, a transparent age-related sample emerges. Hospital-presenting self-harm is extra frequent in youthful girls aged 25–39 than in girls aged 40–59, and inside midlife it declines steadily throughout successive five-year age bands. Girls aged 55–59 current far much less typically than girls aged 40–44. The consistency of this sample throughout each between-group comparisons and within-group comparisons means that self-harm, as a hospital-visible behaviour, turns into much less frequent as girls transfer from younger maturity into and thru midlife. Throughout all midlife age teams, self-poisoning was the dominant technique of self-harm. With growing age, overdoses involving benzodiazepines turned extra frequent, whereas patterns of repetition additionally modified. There was no distinction in 12-month repetition of self-harm between age teams, however longer-term repetition decreased with age, indicating that older midlife girls had been much less prone to re-present repeatedly after an preliminary episode. These findings about self- hurt stand independently of any conclusions about suicide, and are per earlier analysis on this space.
One attainable method of understanding this age-related decline in self-harm, is developmental. In my very own work on the psychodynamics of self-harm (Gibbons, 2024a), I’ve described self-harm as an acting-out behaviour that happens when emotional expertise can’t be adequately symbolised, such that misery should be communicated throughout the physique boundary quite than by phrases. From this attitude, declining self-harm with age might replicate an elevated capability to mentalise and articulate misery verbally quite than enact it bodily. This doesn’t indicate that misery diminishes with age, however that its mode of expression might change, with the physique turning into much less needed as a website of communication when symbolic thought is extra out there. Importantly, this interpretation issues self-harm solely and tells us nothing about suicide.
What, then, does the examine inform us about suicide? As a result of the cohort is restricted to girls who had already self-harmed and offered to hospital, the suicide findings apply solely to a selected subgroup of those that die by suicide. This is a vital energy, because it permits long-term outcomes to be examined in a clearly outlined inhabitants, but it surely additionally highlights a persistent limitation in suicide analysis: the tendency to give attention to what’s most seen to providers quite than the place most suicide deaths truly happen, particularly amongst folks not in touch with psychological well being providers, lots of whom don’t have any recorded historical past of psychological sickness.
The size of follow-up on this examine is essential. Index self-harm shows occurred between 2003 and 2016, with mortality outcomes tracked till the tip of 2019. Contributors had been due to this fact adopted for as much as roughly 16 years, with a minimal follow-up of round three years. Suicide analyses had been performed utilizing person-years-at-risk, confirming that this was a long-term final result examine quite than an examination of short-term suicide danger following self-harm. Over this era, the chance of dying by suicide was low, round 1 in 100. Of the 6,147 girls who may very well be traced for mortality follow-up, 77 died by suicide, comparable to roughly 1.2–1.3% of the self-harm–skilled midlife cohort. This discovering is per different modern cohort research of suicide following hospital-presenting self-harm Hawton et al., 2015).
Suicide mortality was not evenly distributed throughout midlife. Inside the cohort, suicide mortality elevated with age, such that girls aged 55–59 skilled greater than twice the suicide mortality of ladies aged 40–44, though absolutely the variety of deaths remained small in all age bands. The examine doesn’t present that suicide follows escalating or repeated self-harm, that it may be predicted from the frequency of self-harm, or that elevated scientific contact prevents it.
These findings are attention-grabbing, however they are often interpreted in multiple method. One query the examine doesn’t handle straight is how this sample compares with males in the identical age teams. Proof from giant hospital-presenting self-harm cohorts, suicide mortality in males will increase with age; in register-linked Scandinavian knowledge, males within the 45–59 age band have greater first-year suicide incidence than males aged 30–44, and enormous English multicentre research additionally present a optimistic age–danger relationship (Geulayov G 2019, Tildeman 2015). This raises the likelihood that what we’re seeing in midlife girls isn’t merely a organic story, however a relational and developmental one, formed by gendered pathways of misery, visibility, and help-seeking.
What this examine in the end reveals is that self-harm and suicide should not interchangeable outcomes, however completely different expressions of misery that unfold throughout midlife in numerous methods.
Implications for observe
There isn’t any present proof that suicide could be predicted, and self-harm and suicide should not interchangeable phenomena. Suicidal ideation has a low predictive worth, and though self-harm is related to elevated danger at a inhabitants degree, it doesn’t slim down a gaggle liable to suicide in a method that’s clinically helpful.
Our function in psychological well being is to not predict suicide; that could be a distortion of our reality-based process. When somebody expresses suicidal ideas or self-harms, they’re speaking misery. These acts might sign a lack of capability to mentalise, a collapse within the capacity to place emotions into phrases. Our process is to not forecast demise, however to show in the direction of the particular person and ask what these communications imply. If we may help people restore symbolic considering and title their misery, we usually tend to assist them re-engage with life. As in different areas of healthcare, our goal isn’t solely to forestall demise, however to assist folks dwell.
For girls, midlife is usually a interval of profound transition. It could contain organic change, but in addition loss, reorientation and the renegotiation of id. It could be a time of mourning of youth, fertility, roles and relationships, but in addition a time of reawakening and consolidation, a reclaiming of authority and expertise. The stigma directed at girls as they age must be challenged. Cultural narratives painting decline and invisibility, but many ladies expertise midlife as a interval of integration and energy. Personally and clinically, I’ve by no means felt extra seen or highly effective than at this stage of life.
In abstract, the implications for observe should not about refining prediction, however about deepening formulation. Every lady presenting in midlife requires a person, biopsychosocial formulation that takes significantly her historical past, her relational world, her bodily well being, her social and financial context, and the developmental transitions of this stage of life.
Expressions of suicidality or self-harm ought to be understood as communications of misery, typically rising when feelings can’t but be symbolised. Our function is to assist restore that capability, to assume, to call, to mourn, and to make which means, quite than to focus narrowly on danger prediction. Good observe is considerate, relational and contextual, not algorithmic.
Our goal isn’t solely to forestall demise, however to assist folks dwell. Every lady presenting in midlife requires a person, biopsychosocial formulation that takes significantly her historical past, relational world, bodily well being and social context.
Assertion of pursuits
Rachel Gibbons is a guide psychiatrist, psychoanalyst and group analyst. She has written beforehand in regards to the menopause transition and the dangers of over-biological framings of ladies’s psychological well being. AI was used as a part of the drafting course of for this weblog. Rachel Gibbons reviewed and edited all content material for accuracy and appropriateness.
Edited by
Laura Hemming.
Hyperlinks
Major paper
Caroline Clements, Harriet Bickley, Keith Hawton, Galit Geulayov, Keith Waters, Jennifer Ness, Samantha Kelly, Ellen Townsend, Louis Appleby, Nav Kapur. (2025). Self-harm in girls in midlife: charges, precipitating issues and outcomes following hospital shows within the multicentre examine of self-harm in England. The British Journal of Psychiatry, 227(1), 456-462.
Different references
Cleghorn, E. (2021). Unwell Girls: A Journey Via Drugs and Fantasy in a Man-Made World.
Geulayov G, Hawton Ok, Casey D, et al. (2019). Suicide following presentation to hospital for non-fatal self-harm within the Multicentre Research of Self-harm in England. The Lancet Psychiatry, 6(12), 1022–1030.
Gibbons, R. (2024a). The psychodynamics of self-harm. BJPsych Advances, 31(3), 164-172.
Gibbons, R., (2024b). Understanding the psychodynamics of the pathway to suicide. Worldwide Evaluate of Psychiatry, pp.1-9.
Gibbons, R. (2025a). The menopause transition: a name for a holistic method. BJPsych Bulletin, 1-3.
Gibbons, R. (2025b). Rethinking suicide prevention: from prediction to understanding. BJPsych Worldwide, 22(4), 131-134.
Hawton Ok, Bergen H, Cooper J, et al. (2015). Suicide following self-harm: findings from the Multicentre Research of Self-harm in England, 2000–2012. Journal of Affective Problems, 175, 147–151.
Tidemalm D, Beckman Ok, Dahlin M, Vaez M, Lichtenstein P, Långström N, Runeson B. (2015). Age-specific suicide mortality following non-fatal self-harm: nationwide cohort examine in Sweden. Psychological Drugs, 45(8), 1699–1707.
Shneidman, E. S. (1993). Commentary: Suicide as psychache. Journal of Nervous & Psychological Illness, 181(3), 145-147.
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