to the editor: In this informative Curbside Consultation, Drs. Bode and Roberts state that “In addition to high-risk sexual behaviors, higher rates of sexual abuse are found in patients with nonsuicidal self-injury.” I assume they mean that patients with nonsuicidal self-injury are more likely to have a history of sexual abuse. This would not appear to be the case, based on a review article and meta-analysis that found the relationship to be relatively small.¹ The meta-analysis concludes that “Theories that childhood sexual abuse has a central or causal role in the development of self-injurious behaviour are not supported by the available empirical evidence. Instead, it appears that the two are modestly related because they are correlated with the same psychiatric risk factors.”

Would the authors agree, in light of this information, that childhood sexual abuse does not have a causative and central role in nonsuicidal self-injury?

in reply: Thank you to Dr. Ewald for your contribution to the discussion of this difficult subject. Although we agree that the evidence may not support a causal relationship between a history of sexual abuse and nonsuicidal self-injury, there is a statistically significant and clinically relevant association.¹ The prevalence of childhood sexual abuse in the general population is high (approximately 17 and 8 percent for adult women and men, respectively), and it is associated with other nonsuicidal self-injurious comorbidities (e.g., depression, eating disorders, substance abuse).² We encourage routine questioning about a history of sexual abuse in patients with nonsuicidal self-injury, because knowledge of abuse can help physicians manage patient safety and can influence future therapy. A biopsychosocial approach such as HEADSS (home life, education, activities, drugs, suicide, sex) provides a simple, commonly used framework to evaluate patients with nonsuicidal self-injury for associated comorbidities, including a history of sexual abuse.