There has been a dramatic increase in the hospitalisation of young Australian women who have intentionally harmed themselves, according to a new .
Figures released this week by the Australian Institute of Health and Welfare show that in 2010-2011, there were more than 26,000 hospitalisations for self-harm across Australia.
The majority of those treated were women, with the most marked difference being in the 15 to 19-year-old age group, where the rate for girls was almost three-times that of boys.
Over a 10-year period, intentional poisonings and overdoses among women rose significantly and the number of cases of self-harm using a sharp object more than doubled.
Meanwhile, a separate published by the state health department showed a further sudden jump in self-harm among young women from 15 to 24, between 2010-2011 and the previous year.
Sydney-based child and adolescent psychiatrist, Professor Philip Hazell, says that spike could be due to a change in reporting procedures.
"The 2010-11 figures coincide with the introduction of the four-hour rule in emergency departments, so people who would have previously perhaps waited in the emergency department while the effects of their overdose wore off or they were treated for their cut and discharged, now became part of the hospitalised statistics," he said.
However, that does not explain why there was no corresponding spike for men and for women in the other age groups, and Professor Hazell agrees it may actually be the case that there was a genuine jump in self-harm rates.
The figures for 2011-12, due to be released later this year, will confirm whether there is a trend.
But Professor Hazell says most injuries are inflicted in secret and are often covered up with clothing so the hospital figures only tell part of the story.
"They represent the tip of the iceberg. Only about one-in-10 people who self-harm come to clinical attention," he said.
"The prevalence rates for example in 15 to 16-year-olds are close to 10 per cent in girls and about three or four per cent in boys, we know that from a big international study that Australia contributed to a few years ago."
"All frontline clinicians will tell you that it feels like there has been a surge or a steady increase in self-harm rates for over a decade."
Professor Hazell says women usually hurt themselves as a coping mechanism and it is a symptom of a serious underlying issue such as stress, depression, relationship difficulties, bullying or abuse.
"For most people it seems to be a way of relieving immediate distress," he said.
"So people who engage in self-harm say that for a period after they self-harm they feel a bit better.
"That period can be a few minutes, sometimes it can be a few hours, sometimes a few days. That's the typical scenario.
"It looks like for very young adolescents they’re more likely to do it because they feel bad about themselves.
"They’re trying to punish themselves."
That was the case for 25-year-old Bec, from Sydney.
"I was about 12 when I first started self-harming," Bec said.
"At about that age I started suffering from depression quite badly and suffering from depression you convince yourself that you're a bad person, you're just not right, and part of that can turn into this idea of you need to be punished, you need to punish yourself.
"But then, as I grew a little bit older and the depression continued to get worse there were long periods of my life when I wasn’t actually sad, I just couldn’t feel anything, just complete numbness to the world and from there self-harming turned into a way of actually being able to feel something."
Megan, from Brisbane, also 25, has a similar story.
"I started self-harming when I was 13," she said.
"I can't really say exactly why I did it but I think growing up I wasn't that great at expressing my emotions or talking to people and I guess it was a way to feel something.
"Having such low self-esteem, seeing damage done to yourself really kind of justifies your negative existence.
"So seeing a cut or a scar on yourself it's really kind of putting you in your place, which is 'I'm worthless', 'I'm nothing', 'I'm ugly'."
Professor Hazell says that in most cases, the self-harm does not escalate.
"The pattern seems to be that if people engage in self-harm they've usually stopped within about five years; about half of the people who self-harm stop within a year," he said.
But for others, like Bec and Megan, the behaviour becomes addictive, which Professor Hazell says could be due to both emotional and physical dependence.
"The theory is that when we experience pain our body releases endorphins which are natural morphine-like substances which give us a bit of a high or make us feel better," he said.
"In fact one of the things we speak to people who self-harm about is whether they have ever tried other things that might give them the same relief other than hurting themselves, such as exercise."
He says the higher risk among girls than boys could also have a biological explanation.
"We're speculating here but it coincides with the age band at which mental health problems typically begin and where there is a separation between males and females in the incidence of depression and from then on it's more common in women," he said.
"We assume it's something to do with hormonal changes that occur at puberty and there is a direct association between advances in puberty and self-harming behaviour in women but not men."
Dr Alex Parker from Headspace, the national youth mental health foundation, says changing social factors may also be playing a role.
"The period of transition from adolescence to adulthood has become a longer period over the past couple of decades," she said.
"When you think about those traditional markers in terms of how we knew someone had become an adult, such as moving out of home, getting married, getting a fulltime job, all those markers seem to be further delayed now.
"Young people are still at home, still studying potentially late into their 20's and marrying later as well.
"So that period of transition is a lot longer and therefore the risks associated with what can sometimes be a difficult time are also extended."
Another factor which may be having an impact on rising self-harm rates is the rapid uptake of new communication tools.
"Girls commonly turn to their friends and peers as their primary source of advice," Dr Parker said.
Surveys show those conversations are increasingly had via social websites like Instagram and Tumblr and mobile phone messaging apps such as Snapchat and Kik.
While there are good help sites, such as the one run by Headspace, , Dr Parker says there is also the potential to spread self-harm using social media sites and apps.
"Having online communities or using the internet can provide social support to young people who may be stigmatised or maybe isolated," she said.
"But then, this needs to be balanced with the concern over 'social contagion', over the possibility that we’re normalising a behaviour that is of concern and also sensationalising it as well."
Graphic descriptions, pictures of injuries and even messages of encouragement can be found all too easily by internet and mobile phone users of any age.
Megan says going online perpetuated her problem.
"Sometimes it can have a very ugly impact and actually be really triggering for you and make you want to self-harm or make you feel even worse than you did when you initially went out seeking help," she said.
"There are some sites in particular that would glorify it or support it and say, you know, 'this is my body I can do whatever I want'.
"When you're in that mind frame when you're depressed, vulnerable, using maladaptive coping mechanisms to deal with your issues, going to websites like that and making friends with people like that on the internet is probably the worst thing that you could do for yourself."
That is frightening for parents, who often do not have the skills to follow their children into online and mobile worlds and protect them from the dangers there.
Dr Parker urges active understanding.
"Knowing how often their child is using the internet, having discussions about safety, having times where their use needs to be outside of their bedroom so you can at very least see some of the ways in which they are using the online space," she said.
"The really important thing is having that open discussion and checking in with them and asking them and letting them know that they've got a safe place to come to if they're concerned, that they can talk to their parents about things that are happening online."
Professor Hazell agrees that it is important to make sure the channels of communication stay open.
He says if you think someone you know is hurting themselves intentionally, you should ask about it, even if you are worried it might prompt that very behaviour.
"The risks of not talking about it are much greater than the risks of talking about it, so we tell people it's better to be upfront and open about it," Dr Hazell said.
"Having a dialogue with the child which is not punishing or punitive, telling them they’re not in trouble but you want to know that they're doing it. And ask them what’s bothering them."
Like many people who have self-harmed into their adult years, Megan found that the key to recovery was reaching out for help.
"You can create even more isolation for yourself by just going online but you need to reach out to professionals, you need to reach out to real people in the real world who can give you real support," she said.
Many young women who have recovered from self-harm report that once their underlying mental health issues were being treated, the urge to hurt themselves eased.
Then they were able to use distraction techniques to delay and stop the self-harm and eventually they learnt to replace the urge with healthier coping strategies.
Dr Parker says different methods work for different people.
"Sometimes doing some exercise can really help; writing down any negative thoughts in a journal or on a piece of paper and then ripping them up; hitting a punching bag; talking to a friend; sometimes using a red pen to mark the skin instead of cutting; flicking a rubber band on your wrist; or holding ice in your hand until it starts to get really cold."
Bec says she was given some very useful advice by her psychologist.
"Normally when you want to self-harm it is actually a really fleeting desire or moment, so find something to do for 15 or 20 minutes," she said.
"Just calling up friends to ask how their day is, going out seeing a movie, watching a TV show, knitting if that’s what you like. That really helped."
It sounds simple enough, but recovery can be slow and difficult.
As Bec says, it is important not to think that struggling means you are a weak person.
"Choosing not to harm anymore is a strong and brave decision," she said.
"But I won’t lie, I do think about it sometimes, because for such a long time it was my first fallback.
"So often when I’m in periods of high stress or I stuff up at work I don't want to self-harm but there are moments where I do think about it. So I think you never really finish with self-harming but you certainly get to the point where you are in control of it."
The good news is that while the physical scars from self-harm may remain visible forever, the emotional scars can fade.
"When I started to get to the point when I realised it had been a day since I'd even considered self-harming, and then it gets to the point where it's been a week since you’ve even thought about it and then it gets to a month and then it gets to two, that's when you start to feel empowered," said Bec.
"It's when you realise that you've actually overcome something that was controlling you and controlling your life, and you are better and you’re bigger than that."
Almost 60 women responded to an ABC Online callout to share their own experiences for this article and there were some strong similarities among their success stories.
Here's a selection of the responses.
If you have information that you feel is pertinent to this story, .
If you or anyone you know needs help there are a number of services you can contact - phone Lifeline on 13 11 14, Kids Help Line on 1800 55 1800, or Youth BeyondBlue on 1300 22 4636.
Online services are also available at , or .