Impact of Web-Based Sharing and Viewing of Self-Harm–Related Videos and Photographs on Young People: Systematic Review

Introduction

Background

Young people who self-harm engage in more web-based activities than others of a similar age [1]. There is a large presence of self-harm–related materials [2], such as blogs [3,4], large social media groups [5], thousands of highly viewed videos [6], websites [7], and dedicated online communities [8]. The nature of internet use is constantly evolving. Platforms such as Instagram and Tumblr have increased in popularity for self-harm communities, partly because they are image based [9]. A total of 44.00% (528/1200) of surveyed adolescents reported Instagram to be an important part of their daily lives [10], and internet searches for suicide are increasingly returning graphic imagery [11].

Mental imagery plays a role in determining future behaviors [12]. It is thought to be more emotionally evocative than verbal thoughts, with stronger links to affect [13]. Individuals who experience suicidal ideation often report flash-forward detailed imagery, similar to flashback imagery in posttraumatic stress disorder, related to suicidal acts [14,15]. Most youths who self-injured reported mental imagery when the urge to self-injure was strong [16,17]. Emotion-laden mental imagery of self-harm may play a role in motivating behaviors toward or avoiding self-harm [17].

In addition to the role of mental imagery, a growing body of literature has explored the role of exposure to self-harm images through the media [8,18,19]. Although self-harm is a largely hidden behavior, images of self-harm are commonly shared on the internet. This is often done anonymously, with individuals continuing to hide their self-harm in the offline world [20]. Participants have reported reduced loneliness and the use of images to curb self-harm urges on the one hand and reinforcement and triggering of self-harm on the other [8]. Previous systematic reviews regarding internet use and self-harm, although not focused on images, similarly suggest both positive and negative impacts of images and videos [18,19]. The growing popularity of image-based platforms and high-profile stories of the risks has stimulated an exponential increase in research related to web-based self-harm imagery. Given recent moves to remove or blur self-harm imagery or content posted on platforms such as Instagram in response to concerns of bereaved parents [21], it is important to understand the impact of posting or viewing self-harm images on young people.

Aims

This study aims to systematically review research related to the viewing or sharing of web-based self-harm or suicidal behavior–related videos or images in children and young people to explore the impact on emotions and behaviors of viewing or reposting images or videos of self-harm, the impact of posting images or videos of self-harm by individuals who self-harm, and whether certain aspects or types of images or videos impact outcomes.

Methods

Previous Reviews

Web-based content related to video and images of self-harm has been included as part of previous systematic reviews by our research group [18,19], but it was not our main focus. We adapted the search strategy used to specifically identify research on this topic. An electronic literature search was conducted from January 01, 1991, (the year the internet was made publicly available) to February 20, 2019, to ensure a comprehensive overview of the existing literature.

Search Strategy

The core databases CINAHL, Embase (excluding MEDLINE journals), PsychINFO, SCOPUS, and MEDLINE were searched alongside topic-specific websites (Campbell, Centre for Mental Health, Department of Health, Mental Health Foundation, Department of Health, Social Services and Public Safety for Northern Ireland, National Health Service (NHS) Scotland, and the Royal College of Psychiatrists) and meta-search engines (Google and Google Scholar). The search terms were grouped into 4 categories:

1. Internet use: Free text “Aol” or “Askfm” or “Bebo” or “blog*” or “chat?room*” or “cyber*” or “discussion forum” or “e?communi*” or “e?material$” or “Facebook” or “googl*” or “hashtag$” or “instant messag*” or “internet” or “live chat*” or “live journal$” or “MSN” or “Myspace” or “on?line” or “online” or “podcast*” or “social network*” or “spam*” or “tweet*” or “Twitter” or “troll” or “virtual*” or “web” or “whatsapp”. MeSH terms “Internet,” “Social media,” “Social networking”
2. Images nonspecific to internet: Free text. “imag*” or “galler*” or “photo*” or “picture$” or “video*”. MeSH terms “Video recording”
3. Images specific to the internet: Free text. “meme” or “Pinterest” or “Tumblr” or “vine” or “vlog*” or “YouTube” or “snap*” or “gif$” or “selfie$” or “Flikr” or “camera” or “filter” or “reddit” or “Instagram” or “tik tok”
4. Self-harm and suicide: Free text. “Automutilation” or “Distress*” or “emotion*” or “NSSI” or “SIB” or “suicid*” or ((oneself or myself or self) adj2(cut* or harm* or hurt* or kill or injur* or mutilat*)). MeSH terms ‘Self-injurious behaviour’, ‘Stress, Psychological’

The terms were combined as follows (internet AND images nonspecific to internet terms) OR (images specific to the internet). The self-harm and suicide groups were combined with the results from the above search.

Selection Criteria

Articles were included if they examined web-based viewing or sharing of images or videos related to self-harm or suicidal behavior or, videos and images viewed or shared by individuals who experienced suicidal ideation, suicidal behavior, or self-harm. Self-harm refers to any intentional act of self-injury or poisoning, independent of motivation or suicidal intent [22]. This definition is very general, as the motivation or degree of suicidal intent is difficult to assess and may vary between individuals and over time. Articles were required to include primary empirical data and be published in peer-reviewed journals. The results were not restricted by the location. Only English language articles were included. Review articles, single case studies, editorials, conference abstracts, or other grey literature were not included. The reference lists of all review articles were manually screened for potential eligible articles. Participants had to be aged 24 years or under or the study population had to have an average age of 24 years and under. If age was not specified, participants had to be described as children, adolescents, young people, or young adults. Where articles examined more than 1 age group, only data for the age group fitting these criteria were analyzed.

Two independent reviewers (AM and LB) manually screened titles. Any disagreements were resolved by consensus or discussed with a third expert reviewer (AJ). Duplicates were removed. Titles that had no relevance and gray literature were excluded from the title screen. A record was kept of all discarded articles, including the reason for exclusion. The remaining titles with abstracts were screened for eligibility (AM and LB). Full-text articles were obtained where suitability could not be determined based on the title and abstract.

Data Analysis

A previously developed data extraction sheet [19] was used to record the findings (Multimedia Appendix 1). Additional fields were added to examine features specific to images and videos (eg, platform moderation, trigger warnings, the nature of the images or videos, and the impact on the viewer). Two reviewers (AM and LB) independently extracted the data from each article. Any inconsistencies in data extraction and quality scores were clarified by consensus or through discussion with a third expert reviewer (AJ).

The heterogeneous and largely qualitative nature of the studies precluded any meaningful combination of results through meta-analysis. Therefore, narrative synthesis was employed. On the basis of published guidance [23], this narrative synthesis examined a number of key aspects of each article. Comparisons were made regarding the way in which self-harm imagery was examined across studies and internet platforms. The influence of heterogeneity was explored further, including differences in populations studied, differences between various platforms, measures employed, and outcomes studied.

Articles were amalgamated and grouped into categories. These categories were inductively generated following initial reading and data extraction of articles and were cross-checked by members of the study team (AM, LB, and AJ). Positive influences of viewing or sharing of images and videos were defined as a perceived reduction in psychological distress, reduced suicidal ideation or self-harm, and advice on how to seek help and encouragement to do so. Negative influences were defined as results indicating increased psychological distress, increased frequency or severity of self-harm or suicidal ideation, provision of information on methods of self-harm or suicide, and self-harm behaviors being encouraged [19]. Positive and negative influences were examined in relation to the population studied, internet platforms (eg, Instagram and Tumblr), and specific features of images and videos.

The quality of the included articles was assessed according to the Critical Appraisal Skills Programme (CASP) [24], as described previously [19]. The CASP tool assesses various aspects of study design, including sources of bias, data collection, clarity of results, and appropriateness of conclusions. CASP does not specifically recommend any scoring or grading system. We adopted a scoring system used previously [25] (≤50% of criteria low quality, 50%-74% moderate, ≥75% high quality, and no criteria weighting applied [26]). Quality assessment was conducted by two independent reviewers (AM and LB) for each article.

A protocol for the systematic review was registered with PROSPERO (international prospective register of systematic reviews) [27].

Results

Screening Process

Figure 1 shows the results of the search strategy and screening process. A total of 19 independent studies (20 articles) were included. Of which, 4 studies focused on images, 10 studies (11 articles) on videos, and 5 on both images and videos. Two articles were based on a single data set of 100 videos [6,28]. A summary of the included articles, quality scores, by category of study is presented in Tables 1-3. Studies came from across the world (United States, n=7; Canada, n=4; United Kingdom, n=2; Germany, n=2; Australia, n=1; and multiple countries, n=3). There were 4 quantitative, 9 qualitative, and 7 mixed methods articles. In total, 11 articles were rated as high quality, 7 as moderate, and 2 as low. Tables 1-3 provide summaries of the included studies.

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Categories of Studies

In total, 12 studies (13 articles) reported an analysis of images or videos related to self-harm or suicidal behaviors over a range of platforms (multiple sources, n=2; YouTube, n=6; Instagram, n=2; Tumblr, n=1; and Twitter, n=1). Three studies examined the perspectives of individuals on the impact of sharing and viewing web-based images or videos of self-harm [9,38,39]. Furthermore, 4 studies (1 high and 3 moderate quality) examined web-based interventions using videos [40-43]. All 4 studies reported the potential for positive impacts. Some studies [31] made a distinction between photographs of nonsuicidal self-harm and suicide attempts, but the criteria for these distinctions were often unclear, so the term self-harm is used throughout.

Use of Hashtags

Moreno et al [36] examined the nature of ambiguous self-harm–related hashtags (eg, #selfharmmm). At the time of this study, Instagram’s terms of use (since revised [21]) blocked users from searching for the hashtag #selfharm. As a result, a number of ambiguous hashtags emerged to bypass the restrictions. The hashtag #selfharmmm was used to identify a number of other ambiguous hashtags linked to self-harm-related content. Such hashtags included #blithe, #selfinjury, and #ehtilb. The number of search results for each hashtag grew substantially over 150 days. Search results revealed a wider group of hashtags #mysecretfamily present across platforms, referring to a range of mental health issues, of which #cat represented self-harm.

Ethical Approvals

Ethical approval was stated as unnecessary in 5 of the 13 articles examining content across platforms because of the public nature of the internet sources. Of the 13 articles, 3 articles stated that they had received institutional review board ethical approval and only 6 included any discussion of ethical issues, such as protecting individual identities or sensitivity in disseminating results, although the content was likely to have been created by potentially vulnerable children and young people.

Platforms

Image-Based Platforms

Two studies examined self-harm content on Instagram [31,36]. Both found considerable image-related self-harm content. One examined photographs of self-harm over a 4-week period, investigating the nature of the pictures, associated comments, and timing of posting behavior [31]. Most photographs depicted wounds with mild or moderate severity. Pictures were generally posted in the evenings. Most comments on self-harm–related posts were part of a more general discussion (3291/6651, 49.47%), with 11.58% (770/6651) asking the user to stop self-harming [31]. One study examined Tumblr posts [32]. Posts that were comforting, supportive, or related to prevention made up 8.00% (220/2750) of all posts. Posts interacting with other users made up 9.05% (249/2750), of which 47.0% (117/249) provided emotional support and 51.0% (127/249) sought or provided advice. Of those seeking or providing advice, 40.9% (52/127) provided positive or supportive advice, whereas 25.1% (32/127) provided potentially harmful advice, including advice on concealment.

One qualitative interview study found that Tumblr was often reported as the preferred platform because of the ease of searching for and sharing of images, perceived anonymity, and lack of moderation compared with other social media sites. This freedom to access and post severe images of self-harm was reported to lead to the normalization and exacerbation of self-harm for some participants [9].

Video-Based Platforms

Seven studies (8 articles) [2,6,28,30,32-35] analyzed YouTube videos, of which 3 (4 articles) focused on self-harm–related videos [2,6,28,35]. Although visual representations of self-harm were common, two-fifths of YouTube videos in one study exhibited a message encouraging help seeking [2]. Analysis of 100 videos found that 53.0% (53/100) were educational, often discouraging self-harm (26/100, 26.0%) [6]. Comments on this set of videos mostly shared personal experiences (38/100, 38.0%) [28]. There were no significant differences in the types of comments based on the number of views, ratings, or types of videos. An examination of videos concerning self-harm first aid tips found 28% (11/40) of videos included a disclaimer indicating that self-harm was acceptable providing certain safety precautions were followed [35]. Other YouTube videos varied in content, including fire challenge videos in which an individual doused themselves in a flammable liquid, set themselves alight, and attempted to extinguish the flames before serious burns are inflicted [29]. This was 1 of only 2 studies [29,37] included in this review in which the majority of participants were male (45/50, 90%).

An analysis of Twitter posts found images and videos related to self-harm, but these were not graphic in nature [34] and included images of celebrity tattoos covering self-harm scars with the message stay strong. These images were shared with positive messages of growth and recovery. Video links tended to be of individuals sharing their own stories.

Graphic Imagery

Images rather than text-based interactions have been reported as the primary reason for using the internet for self-harm purposes in semistructured interviews [9]. The nature of images was important in terms of outcomes. It was commonly expressed that bluntly gruesome photos [39] (eg, flesh, open wounds, and blood) were more triggering than pictures of scars and healing wounds [38]. Results from internet searches varied based on the search terms used, with the term ways to kill yourself eliciting a high proportion of sites with evocative images (20/43, 47%) [7]. Platforms vary according to the degree of graphic imagery. Visual representations of self-harm were common on YouTube. The majority of videos showed severe and open wounds and acute scarification, and 1 video portrayed 3 clips of suicide attempts [2]. Analysis of 100 videos similarly showed that images of self-harm were common (64/100, 64.0% of videos), with 28% (14/50) of character videos depicting live acts of self-harm [6]. A large number of self-harm images are posted daily on Instagram. Of 2826 self-harm images examined in one study, 39.60% (1119/2826) were rated as mild in severity (ie, superficial scratches), 47.78% (1350/2826) as moderate (ie, deeper cut and blood flowing), and 12.60% (356/2826) as severe (ie, very deep cut or a large amount of deeper cuts and blood), with 93.06% (2630/2826) of images depicting cuts [31]. In another study, 17.7% (127/718) of Tumblr posts on self-harm or suicide were graphic images or video clips [32].

A range of emotional reactions and impacts on the viewing or sharing of images or videos are described in Table 4.

Negative Reactions and Impacts

Anger and hostility in response to images or videos were reported in 3 studies [28,31,34]. Other emotional reactions included sadness, shock, and concern [39,40]. Some have described ambivalence or simply viewing photographs to pass time [39]. Images having the potential to exacerbate self-harm through triggering, normalization, competition, or imitation have also been described [9,38,39].

Triggering

The triggering role of imagery was reported in 3 qualitative interview studies [9,38,39]. A third of the participants reported that photographs triggered self-harm urges [39]. Participants reported viewing images as part of a ritualistic practice to be triggered before harming themselves to self-harm more severely [9]. Both triggering and alleviating effects of images have been reported [39]. Whether the material was triggering was dependent on the viewer’s mood. If an individual was already determined to self-harm, then looking at images would encourage urge, whereas if they were in a positive mood, the images would have minimal impact [38].

Normalization and Competition

There were reports of web-based engagement exacerbating self-harm due to normalization and exposure [9]. A sense of competition was reported in all 3 qualitative interview studies [9,38,39], with individuals desiring to emulate the depicted harm while chiding themselves or receiving negative comments from others when they failed to engage with more sophisticated and severe techniques [9]. Participants reported negative feelings regarding failure to harm themselves as severely as the injuries shown in photographs [38]. There were also reports of needing to make wounds worse to be a valid self-injurer [39]. A strong correlation between male informants and negative statements was found in 1 study, with 80% (4/5) of the statements expressing competitive reactions [39].

Imitation

Brown et al [31] examined several possible markers of imitative behavior on Instagram, including comments on photographs and a time-related analysis of posts. Pictures directly depicting wounds generated twice as many comments as those not depicting wounds [31]. A significant association was also observed between wound grade and number of comments, which could indicate a socially reinforcing function of posts. However, the time-related analysis of images did not indicate any effects of imitation or reinforcement [31]. A separate time series analysis did not find an increase in average monthly emergency department visits for suicide-related diagnoses in Ontario children aged 11-17 years following posting and publicity of a young person’s YouTube video who took their own life [37]. This showed the young person holding up cards telling a story of bullying, mental health issues, and self-harm, with an image of self-harm injuries at the end.

Positive Reactions and Impacts

The production of images was often about memory and proof, with photos forming part of a narrative likened to fading scars. Individuals reported taking photographs for artistic value or their own interest [39]. A reduction in self-harm urges was reported with content creation said to act as an alternative outlet for negative emotions, with the viewing of images acting as a placebo or deterrent [38]. Those who create drawings, poems, and videos, in particular, called the materials a form of art that portrays the feelings behind self-harm, with positive feelings reported when content was reblogged [38].

Reactions of empathy, sympathy, and where people both gave and received help were found across various platforms [31,38,40]. Self-harm photographs were described as a resource for the self-harm community and were said to provide a feeling of solidarity and reassurance of not being alone [38,39].

Prevention and Intervention

Trigger Warnings

Three studies (4 articles) exploring the content of images or videos included an analysis of trigger warnings. These are placed on content by either the uploader, moderator, or platform and are intended as a warning to individuals who may find that the images increase the urge to self-harm. Two articles (based on a single data set of 100 videos) reported that 58.0% (58/100) of YouTube videos related to self-harm did not warn about content [6,28]. Just 2 of 40 self-harm first aid videos contained such a warning [35]. Two peer-moderated and 3 professionally driven sites were examined in an assessment of self-harm across different platforms. Both peer-moderated sites contained trigger warnings. The professionally driven websites did not contain any graphic material, so no trigger warnings were present. Trigger warnings were present on 4 of the 5 YouTube videos included in this study. Of the 5 Myspace groups examined, 3 contained trigger warnings and 2 prohibited self-harm images. Only 1 of the 4 Facebook groups contained a trigger warning, despite the presence of photos and videos in most groups [2].

Alongside user-generated trigger warnings are content advisory warnings on some platforms. Searches for self-harm-related content on Tumblr first provided a screen with suggestions for seeking help or finding more inspirational content, with the option to proceed to the next screen to view the search results [32]. Of the 18 self-harm–related hashtags, 6 generated a warning label on Instagram [36].

Recovery-Oriented Content

Recovery-oriented content was observed in varying degrees across platforms. Among Tumblr posts providing advice, only 13.4% (17/127) suggested professional help or therapy [32], and 2.4% (21/869) of comments on YouTube videos encouraged the uploader to seek help [28]. Some comments indicated that the individual was seeking treatment (83/869, 9.6%), had recovered (62/869, 7.1%), or expressed a desire to recover (33/869, 3.7%) [28]. Recovery-oriented content appeared to be most evident on Twitter, with inspirational quotes and stories of recovery [34].

Interventions

The interventions discussed here include a web-based video component to an intervention designed to reduce suicide or self-harm. The content of these videos was professionally generated and differed from the user-generated content discussed above and contained no graphic self-harm imagery.

The safety and acceptability of a web-based suicide prevention program incorporating video elements in secondary school students was examined in one study [42]. The video component of this intervention uses a host character to deliver verbal therapy and parts of this include video diaries that tell a story portrayed with young people actors. Overall, the intervention did not lead to increases in suicidal ideation or distress, and 71.4% (15/21) of participants rated the video diary component as more enjoyable and helpful than hearing from website moderators or receiving text messages [42]. The impact of a suicide awareness video as part of a web-based intervention to increase adherence to newspaper reporting guidelines in journalism students was examined in another study. Exposure to awareness raising material with or without the video helped to improve responsible reporting of suicide, with the awareness raising video showing the strongest effect [43].

Two studies examined different aspects of The truth about suicide suicide awareness video. This video focused on interviews with people who have lost a loved one to suicide and the testimonials of students who have experienced depression and suicidal ideation. Both studies found video streaming to be a feasible method for delivering a suicide awareness program to college students [40,41]. Predictors of watching the 29-min video to completion were female gender, undergraduate, Asian ethnicity, and higher individualism as opposed to collectivism [41], measured using the individualism-collectivism questionnaire [44]. Asian American students rated the video significantly lower on cultural relevance than non-White Hispanic students [40]. Following viewing of the video, participants expressed a higher awareness of the signs of depression, the need to take immediate action, and to talk openly about suicide [40]. Small increases in distress were found [41]. The importance of an effective debriefing session in a safe and confidential setting for sharing thoughts, feelings, and experiences and to prevent iatrogenic effects of web-based suicide prevention programs using emotionally charged videos was emphasized and successfully delivered on the web [40].

Discussion

Principal Findings

We conducted a systematic review of the literature related to the impact of sharing or viewing web-based self-harm images or videos, exploring intent and interpretation in young people. A total of 19 studies (20 articles) were included. No previous studies have focused on this area [18,19]. We have identified specific features of platforms that contribute to potentially harmful use and of images that may influence the impact on the viewer or sharer.

In recent years, there has been a move away from the once popular self-harm forums to other platforms in terms of use by both individuals and researchers [9,45]. There has also been an increase in graphic imagery identified by self-harm–related searches over time [11], and participants reported image-based rather than textual interactions as the primary reason for internet use [9]. Studies consistently report a large presence of graphic imagery of self-harm on image-based platforms such as Instagram and Tumblr. In contrast, there is less graphic imagery present on Twitter and a greater presence of recovery-oriented content [34]. The difference between platforms was further supported by an analysis of randomly generated posts found with the hashtag #cutting. Instagram posts were found to display the greatest proportion of graphic content, with the smallest proportions found on Twitter [46]. Recovery-oriented resources were congregated on the platforms with the least problematic content. Potentially harmful content appeared to congregate on the platforms that have relatively little moderation, where participants can remain anonymous and search for images easily [9]. The use of videos in suicide prevention interventions has also been examined [40-43]. The content of these videos differed from user-generated materials, such as those shared on social media platforms. Videos included as part of an intervention focused on issues around suicide or self-harm, including interviews with those impacted by suicide [40,41], video diaries delivered by actors [42], and suicide awareness material related to response reporting of suicide by the press [43].

A range of reactions and intentions have been reported in relation to posting or viewing images of self-harm from empathy, solidarity, and the use of images to give or receive help [31,38] to potentially harmful advice suggesting new methods and tips for hiding self-harm, as well as normalization and exacerbation of self-harm [9,39]. This is further supported by recent research describing strong social motivations for posting self-harm content on Instagram as well as the need to document self-harm or recovery [47]. Viewing images as an alternative to self-harm and as a creative outlet were regarded in 2 studies as positive impacts [38,39]. The use of images as a creative outlet for distress was found in a recent analysis across platforms [48]. Reactions of anger, hostility, and ambivalence in posting self-harm images have also been reported [28,31,34].

Self-harm images were reported to be part of a ritualistic practice by all 3 studies that examined user perspectives. Participants reported viewing graphic imagery on the web to evoke the right mood for self-harm, often resulting in more severe injuries [9]. Photographs of fading scars or creative content have been reported to have a positive impact [38,39]. Photographs of fresh cuts or severe injuries are most frequently reported to have a negative impact [9]. Participants reported that viewing more severe injuries leads to negative feelings of failure to achieve the same level of injury or more severe injuries over time [9,39].

There was some evidence of the role of imitation and reinforcement, driven partly by the number of comments generated by self-harm imagery and wound severity [9,31]. Although time series analyses were conducted in 2 studies [31,37], the limitations of these analyses indicate the need for further studies to examine the impact of self-harm imagery. Although the evidence for social contagion is lacking in the papers described here, recent studies relating to the release of the TV series 13 Reasons Why, in which the suicide of a young female is graphically depicted, found this to be associated with a significant increase in adolescent suicide rates [49] concordant with the period in which social media discussions of the series were greatest [50]. This increase in deaths was found despite some individuals reporting positive impacts [51]. The graphic scene was removed following concerns expressed by the suicide prevention agencies. Recent research has suggested a need to think beyond a model of contagion of self-harm behavior and shifting the focus onto other mechanisms of harm and benefit [52]. It has been highlighted that social media often acts to mirror society and that a wider context needs to be taken. For example, gaps in service provision often led people to seek online peer support [52].

Strengths and Limitations

This study provides a comprehensive overview of studies directly examining web-based self-harm imagery or videos in relation to children and young people. The potential for publication bias exists in any literature review. Steps were taken to minimize bias, including conducting an extensive literature search of multiple databases, including topic-specific websites and reviewing reference lists, titles and abstracts being screened by 2 researchers, and data extraction being conducted by 2 researchers for each article. Only English language publications were included in the analysis. Females outnumber males, where this information was available, in all but 2 studies, one of videos related to the fire challenge [29] and a time series analysis of emergency department attendance [37]. One study reported that males were more likely than females to report negative impacts of self-harm images [39]. However, the limited number of males included makes it difficult to draw firm conclusions. Further research into potential sex differences and involving larger samples of males is needed.

Although a number of measures were included in eligible studies, including analyses of content, the impact of self-harm imagery has relied heavily on self-reporting of short-term impacts. This is particularly true for the perceived positive impacts. Future research should aim to understand the long-term effects of continual exposure to such images, as the nature of immediate impacts may change over time. This is highlighted by the recent literature related to 13 Reasons Why, where an increase in suicide rates was found [50], despite some individuals reporting a positive impact of the show [51]. Web-based content has the potential to reach a large audience; as such, a range of emotional reactions is to be expected. It is important that the overall impacts on outcomes such as suicide rates and levels of self-harm are assessed alongside self-report measures to put any reported positive or negative impacts into a wider context. The use of validated outcome measures related to self-harm or levels of distress would strengthen the evidence base in this area.

Although 2 studies included a time series analyses [31,37], both had their limitations. It is not yet clear how and whether any long-term process of imitation would take place on a platform such as Instagram, where images can be searched and viewed long after they are posted [31]. Although the potential impact of a particular video was examined for emergency department attendances, this was confined to 1 region that was not where the death occurred and media dissemination was greatest. This would not have been a measure of self-harm that presented to settings other than emergency departments, such as primary care, or for self-harm in the community that would not be present in health care data. Further research is needed before any conclusions can be drawn based on such evidence. This could include the use of survey data or routinely collected health care data spanning multiple settings (eg, primary and secondary care). Accurately determining the characteristics of young people based on web-based profiles is not always possible. The average age of participants is likely to be younger than that reported, as young people often misrepresent their age to gain access to restricted content [6]. Finally, although self-harm presentations by young people to general hospitals most commonly involve self-poisoning [53], this method of self-harm rarely featured in the images appearing on the internet. Thus, the images that are found largely reflect self-harming behavior most frequently occurring in young people in the community [53], although accessing internet sources before self-harm is common in young people who attend hospital following self-poisoning [54].

Implications

Clinicians working with young people who self-harm should routinely enquire about internet use [54], support them in recognizing and managing triggering content, and encourage healthier web-based behaviors. The powerful role of imagery in evoking emotional reactions and motivating both potentially harmful behaviors, such as self-harm [16], and adaptive behavior [55] could make this an important factor in recovery.

As young people frequently create their own content, guidance to increase safe and responsible depiction of suicide and self-harm image and video-based content are now needed to educate young people as well as media professionals. Recent analysis of videos related to the Blue Whale Challenge on YouTube has demonstrated that although these user-generated videos seek to raise awareness, most videos violate guidance around safe and effective messaging, further underscoring the need to educate social media users and content generators on safe content creation and the factors that may have either positive or negative impacts on vulnerable viewers [56]. Individuals have reported an awareness of the potential impacts of self-harm images and videos and as a consequence add trigger warnings to their own posts [9]. Initiatives could be developed to build on this and to equip young people with the skills to analyze and evaluate their own creative content and to highlight the potential for posts intended as catharsis and therapy for themselves to be potentially harmful to vulnerable individuals. Strategies to improve safety could build on the work of the #chatsafe project and the development of guidelines for safe peer-to-peer web-based communication related to suicide [57]. Such projects could be used to inform parents, teachers, and other caregivers as well as young people. This could improve the safety of image-based platforms.

A small number of studies examined the use of videos disseminated on the web as a means of intervention. Given the large self-harm community using image and video-based platforms, further research into potential interventions is needed to understand how to maximize effectiveness. Content creation can act as an alternative outlet for negative emotions, and the viewing of images acting as a placebo or deterrent could be explored as potential interventions. It has been suggested that educational programs should be developed to inform young people about the impact of the content of posts and how to respond to posts from those in distress [2,57]. A recent pilot study found that hopeful reactions to the self-harm content of YouTube can improve positive attitudes toward recovery [58]. This has the potential to prevent suicide contagion via social media. The use of videos in suicide prevention programs appeared to be promising not just for young people themselves but also for improving responsible reporting of suicide among journalism students [43]. The importance of the cultural relevance of prevention videos has been emphasized [41]. More recent coproduction of suicide prevention material with a popular YouTuber in Hong Kong suggests that this may be an effective avenue for future suicide prevention strategies [59].

Individuals reported an awareness of the potential impacts of self-harm images and videos and added trigger warnings to their own posts [9]. Automated platform content warnings may not have been sufficient [36]. Our results should be discussed in the context of recent changes in policy by platforms, including Facebook [60] and Instagram [21], regarding the posting of graphic self-harm imagery. Changes were made following the death of a young person in the United Kingdom in February 2019 and the subsequent campaign by the family. Instagram announced a ban on all images of self-harm, including pictures showing scars [21]. The particular features of platforms that make them more amenable to harmful use include a lack of moderation and ease of sharing, searching, and viewing of images [9]. Monitoring and regulation of posts may be a positive move toward making these spaces safer. The effectiveness of such policies has yet to be evaluated, and a recent analysis of YouTube content found that content did not comply with YouTube’s policy on self-harm. Most content did not require age registration, and the specific help-related search terms had to be used to access any suicide prevention–related content [61]. Young people often find ways around posting restrictions, such as by using ambiguous hashtags [36] or moving to more hidden parts of the internet. An examination of 1 of these ambiguous hashtags on Instagram has shown that 3 quarters of posts contained a wound, the majority of which did not contain an advisory warning [62]. The use of image recognition software to identify graphic self-harm imagery could have important implications for protecting vulnerable individuals from potentially triggering content [63].

The potential for posting restrictions to reduce positive impacts, such as support and a sense of community, must also be considered as should any potential negative impacts of the removal of content posted by vulnerable young people without consultation. The use of social media to bridge support in service provision, particularly with regard to both giving and receiving peer support, has been further highlighted in recent literature, pointing to the potential inadequacy of a strategy focused on placing pressure on internet service providers to remove all self-harm content. Instead, care must be taken with such restrictions to avoid further harm [52]. Banning images of scars may have the unintended consequence of increasing stigma or removing from individuals the opportunity to share their stories, including those related to recovery. The indiscriminate removal or blurring of images of people with injuries and scars will include those not related to self-harm and could negate the potentially positive impact of fading or healing self-harm scars. Although the results of this review support concern related to safety and exacerbation of self-harm, the potential for positive impacts should not be underestimated. Future research should seek to evaluate the effectiveness of current posting restrictions and to identify the best strategies to reduce risk and maximize positive impacts on participants by incorporating user perspectives. This supports previous calls to better understand how to leverage the unique opportunities afforded by such platforms to reach and engage vulnerable individuals [46,47], with the potential for awareness materials to reach a large audience of vulnerable individuals via social media [64].

We identified no studies examining the role of the Google Images search engine, which has not seen the same restrictions applied to searches for self-harm imagery as social media platforms. There is no social community or moderation of Google images. Google Images does not incorporate the same tools that exist on the main Google search engine, ensuring results related to helplines, and information appears at the top of search results for suicide and self-harm. Typing self-harm into Google images results in a collection of images from across other sites. This is a powerful tool and appears not to have been the focus of this kind of research or policy intervention. It remains an ongoing challenge for the literature to remain current with the changing popularity of various platforms, for example, with the current popularity of Tik Tok, which does not appear to be the focus of current research.

It is important to note that the majority of studies reported here explore immediate or short-term reactions to self-harm content. Future research should aim to understand the long-term effects of continual exposure to such images, as the positive or negative immediate impacts may change over time.

Careful consideration should also be paid to the ethical issues of conducting research on freely available content and the associated implied consent. Future research should ensure the recruitment of males and focus on delineating the specific features of images that may be harmful and the mechanisms involved.

Conclusions

The way in which young people use the internet is continually evolving. An increasing preference is being reported for the use of the internet for image-based rather than text-based interaction with regard to self-harm. Concerns over negative impacts such as exacerbation and normalization of self-harm and sharing of information on new methods or concealment of self-harm are supported by research. However, there can also be positive impacts such as seeking and receiving peer support and viewing images as an alternative to self-harm and as an outlet for negative feelings. Graphic images and photographs of severe injuries are most often reported to have a negative impact. Clinicians assessing distressed young people should routinely enquire about internet use, explore strategies to manage any triggering content, and be aware of helpful sites. The use of images and videos as part of web-based interventions for suicide prevention is an area worthy of further study. Future research should also seek to evaluate the effectiveness of current posting restrictions on social media and to educate clinicians and caregivers on how to encourage healthier web-based behaviors. The combination of appropriate policies by internet service providers and education for individuals may be necessary to allow for the potential positive impacts of web-based imagery while minimizing the potential for harm.