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Open Access

Peer-reviewed

Research Article

The role of childhood maltreatment, current stress, and alexithymia in nonsuicidal self-injury: A sex-specific analysis among Korean young adults

Abstract

Prior research has highlighted various risk factors for nonsuicidal self-injury (NSSI), yet inconsistencies remain regarding their predictive value and sex-specific effects. This study examined how childhood maltreatment, current perceived stress, and alexithymia contribute to the engagement and severity of NSSI, with a focus on sex differences. A total of 731 individuals participated in this study (233 males, 498 females). The sample consisted of 481 individuals with NSSI (124 males, 357 females) and 250 control participants without a history of NSSI (109 males, 141 females). Logistic and multiple regression analyses were conducted separately by sex to test the differential predictive value of the factors. Among males, physical abuse significantly predicted NSSI engagement, and current stress was uniquely linked to greater NSSI method versatility. Conversely, in females, emotional abuse, current stress, and alexithymia emerged as key predictors of NSSI engagement, while sexual abuse, physical neglect, and alexithymia predicted greater severity. These findings underscore the existence of distinct, sex-specific pathways linking early adversity, emotional processing difficulties, and proximal stress to both the engagement and severity of NSSI. Tailoring prevention and intervention strategies to account for these sex-specific patterns is required to improve clinical outcomes.

Citation: Jo E, Kim G, Hur J-W (2026) The role of childhood maltreatment, current stress, and alexithymia in nonsuicidal self-injury: A sex-specific analysis among Korean young adults. PLoS One 21(4): e0340384. https://doi.org/10.1371/journal.pone.0340384

Editor: Homa Seyedmirzaei, Tehran University of Medical Sciences, IRAN, ISLAMIC REPUBLIC OF

Received: May 20, 2025; Accepted: December 18, 2025; Published: April 6, 2026

Copyright: © 2026 Jo et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: Data cannot be shared publicly as the consent provided does not include sharing the acquired data with third parties or external sources. The data contain sensitive information, and participants did not provide written consent for their data to be shared. The release of data is restricted by the Institutional Review Board, and requests for deidentified data may be made under the specific conditions by contacting the corresponding author (j_hur@korea.ac.kr) and the Institutional Review Board (ethics@cau.ac.kr).

Funding: This study was supported by a grant from the National Research Foundation of Korea grant funded by the Korean government (Ministry of Science, ICT & Future Planning) (NRF-2022R1A2C2011467), and by a grant of the Mental Health related Social Problem Solving Project, funded by the Ministry of Health & Welfare, Republic of Korea (RS-2024-00406503). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared no potential competing interests with respect to the authorship and/or publication of this article.

Introduction

In recent years, considerable attention has been directed towards understanding the complex interplay between sex and nonsuicidal self-injury (NSSI), a behavior characterized by deliberate, direct damage to bodily tissue without suicidal intent. A meta-analysis estimated the prevalence of NSSI to be 13.4% among young adults [1]. More recently, a multinational study of first-year college students reported a lifetime prevalence as high as 17.7%, with engagement in NSSI associated with an increased risk of the onset of mental disorder [2]. Furthermore, given that another meta-analysis [3] has suggested that NSSI behaviors paradoxically increase suicide risk, there is no doubt that NSSI has been recognized as a crucial, worldwide public health concern. Several attempts have been made to identify factors contributing to NSSI to develop appropriate intervention strategies, which encompass various approaches, including psychological [4] and pharmacological interventions [5] aimed at mitigating associated clinical risks, such as suicidal behavior.

Despite the clear global health imperative, the role of sex in NSSI risk remains inconsistent. While the female gender has frequently been identified as a potential risk factor for NSSI globally [6–8], this pattern is inconsistent across regions. Specifically, meta-analytic findings published around the same period have presented that sex differences in NSSI prevalence were less pronounced among Asian youth populations compared to those in other continents [7,8]. Globally, NSSI is significantly more prevalent among females, yet in Asian adolescents, this sex difference is attenuated [8] or absent [7]. This unique regional deviation, which suggests that NSSI is proportionally more common among males in Asia than in Western contexts, provides a strong justification for our sex-stratified analysis. Importantly, the lack of conceptual clarity regarding female gender as a risk factor may not stem solely from inconsistencies in prevalence or phenotypic expression (e.g., methods of self-injury) [9,10] but rather from a relative dearth of research examining whether the underlying mechanisms contributing to the engagement and severity of NSSI differ between males and females. Our study thus aims to address this gap by elucidating the specific etiological pathways within this population.

To better understand these underlying mechanisms, extensive empirical work has sought to identify and integrate the key determinants of NSSI. An integrated theoretical model by Nock [11–13] suggests that NSSI is primarily reinforced by its functional consequences (e.g., affect regulation and self-punishment, and peer bonding), and the functions of NSSI develop when distal risk factors contribute to intrapersonal and interpersonal vulnerabilities. Furthermore, this model suggests that distal risk factors (e.g., childhood maltreatment), proximal stressors (e.g., current perceived stress), and emotional vulnerability (e.g., difficulties in emotion processing) are the principal contributors to both the engagement and severity of NSSI.

Early adverse interpersonal experiences, including childhood maltreatment [14] and peer-victimization [15], have been identified as a significant risk factor of NSSI. Among these, childhood maltreatment has been shown to exert a lasting influence on a wide range of adverse mental health outcomes, including NSSI [14,16–18]. However, the direct relationship between childhood maltreatment and NSSI appears less robust than previously assumed, with growing evidence suggesting that intermediary variables (e.g., depression and anxiety) may mediate this relationship [19–21]. Moreover, the effects of childhood maltreatment are often contingent on sample characteristics (e.g., males and females) and subtypes of maltreatment (i.e., emotional, physical, and sexual abuse, as well as emotional and physical neglect) [22–24]. Given that males and females, respectively, can be differentially associated with specific forms of maltreatment [25,26], it is necessary to consider differential pathways between males and females to NSSI engagement. Indeed, Serafini and Canepa [27] highlighted potential differences between males and females in the impact of childhood trauma on NSSI and suicidal behaviors, although further investigation is warranted to expand on these findings, which were based on relatively small samples.

In addition to distal factors, proximal distress plays a significant role in NSSI. A meta-analysis by Liu and Cheek [28] identified a small but statistically significant relationship between proximal life stress and NSSI. This association has been substantiated through ecological momentary assessment (EMA) studies, which demonstrate that daily fluctuations in stress levels significantly predict NSSI engagement on a given day [29,30]. Similarly, daily diary studies have found that higher levels of current perceived stress are associated with increased likelihood of NSSI thoughts [31]. Despite these findings, there remains a paucity of research examining how distal and proximal risk factors might jointly influence NSSI behaviors, particularly within sex-stratified models.

The bulk of the literature suggests that individuals who engage in NSSI may have difficulty processing emotions [32,33]. Alexithymia, characterized by the inability to identify and describe one’s feelings, has demonstrated its transdiagnostic role in maladaptive psychological experiences, such as childhood maltreatment [34], as well as NSSI [33]. Regarding NSSI, it suggests that the initiation stage of emotion processing may be disrupted in individuals with NSSI. Numerous studies have indicated that individuals with a history of NSSI exhibit significantly higher levels of alexithymia, suggesting that it may serve as a substantial predictor of NSSI [35–39] and contribute to deficits in emotion regulation [40]. However, compared to studies consistently reporting a strong connection between alexithymia and NSSI among females, research involving malesen is relatively limited and yields mixed results [41]. A recent meta-analysis identified a significantly larger effect size in the relationship between alexithymia and self-harm in females than in males, noting the dearth of studies that have separately investigated males and females within the research samples [42]. Moreover, given the predominantly female participant data in previous studies, it is crucial to examine the potential sex differences in the association between alexithymia and NSSI.

Accordingly, we hypothesized that childhood maltreatment, current perceived stress, and alexithymia would each be significantly associated with the likelihood of engaging in NSSI, with these associations exhibiting sex-specific patterns. We further examined the extent to which these clinical variables were related to NSSI severity, operationalised through method versatility, by conducting sex-stratified regression analyses. Specifically, we hypothesized that subtypes of childhood maltreatment would be associated with an increased risk of NSSI engagement and severity, but that distinct subtypes of childhood maltreatment would be uniquely associated with males and females, respectively. We also hypothesized that current perceived stress would be significantly associated with both NSSI engagement and severity in both males and females. Finally, we hypothesized that alexithymia would be significantly associated with NSSI engagement and severity in females, but not in males. Through this multidimensional, sex-informed framework, the study seeks to elucidate the mechanisms underlying NSSI and thereby contribute to developing more tailored and effective prevention and intervention strategies.

Materials and methods

Participants and procedures

We recruited 835 adults (ages 19–29) fluent in written Korean through online forums and social media platforms. The survey was available for five months, from October 18, 2018 to March 9, 2019. Recruitment advertisements explicitly informed potential participants that the study concerned risk factors related to NSSI and aimed to enroll individuals with and without a history of NSSI to ensure an informed consent process. Following the acquisition of informed consent, participants completed a yes-no forced-choice question regarding whether they had engaged in five or more instances of NSSI in their lifetime. They subsequently completed psychometric questionnaires, reported any history of suicide attempts, and reported demographic data, including sex assigned at birth, age, and educational attainment. All survey questions were administered in Korean. The inclusion criterion was fluency in Korean. Participants were recruited regardless of their lifetime history of NSSI and subsequently classified into two groups: (1) those with a history of NSSI during their lifetime, and (2) those without a history of NSSI during their lifetime.

From the initial sample, 104 participants were excluded for the following reasons: self-harm behaviors did not meet NSSI criteria (n = 43), patterned or otherwise unreliable responses (n = 58), or a history of suicide attempts without NSSI (n = 3). The final analytic sample comprised 731 participants. Participants were divided into two groups: the NSSI group (124 males and 357 females), defined as individuals who reported five or more lifetime NSSI behaviors, and the Control group (109 males and 141 females), indicating those who reported neither a history of lifetime NSSI behaviors nor suicide attempts. Participants who reported a history of suicide attempts without NSSI were excluded due to the small sample size. The study received ethical approval from the Institutional Review Board (1041078–201706-BRSB-127-0C). All participants provided written informed consent prior to data collection.

Measures

NSSI.

The versatility of the NSSI method was assessed using Section I of the Korean version of the Inventory of Statements about Self-injury (ISAS) [43,44]. Section I comprises a behavioral checklist of self-injurious behaviors, for which participants report the frequency of each behavior. In the present study, method versatility was operationalized as a cumulative count, determined by summing the presence of each distinct self-injurious behavior (scored as 1 if present, 0 if absent). This indicator has been validated in prior research, which has shown that greater method versatility is associated with more severe psychopathology and increased suicide risk [45–47]. Additionally, the age of NSSI onset was obtained from Section I of the ISAS, which requires participants to report the date of their first engagement in NSSI.

Childhood maltreatment.

Childhood maltreatment was measured using the Childhood Trauma Questionnaire (CTQ) [48,49], a 28-item self-administered questionnaire evaluating five subscales: emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect. Responses are rated on a five-point Likert scale (1 = never true; 2 = rarely true; 3 = sometimes true; 4 = often true; and 5 = very often true). In the current study, the internal consistency of the CTQ was good (Cronbach’s α = .87).

Current perceived stress.

Current stress over the past month was assessed using the 10-item Perceived Stress Scale (PSS) [50,51], rated on a five-point Likert scale (0 = never, 1 = rarely, 2 = sometimes, 3 = often, 4 = very often). The PSS demonstrated good internal consistency (α = .89) in this study.

Alexithymia.

Alexithymia was measured using the 20-item Toronto Alexithymia Scale (TAS) [52], including subscales for difficulty identifying feelings (DIF), difficulty describing feelings (DDF), and externally oriented thinking (EOT). Responses are reported on a five-point Likert scale (1 = strongly disagree to 5 = strongly agree). The Korean version of the TAS-20 [53] demonstrated good internal consistency (α = .88) in this study. For subscales, DIF (α = .90) and DDF (α = .80) both showed good internal consistency. However, consistent with previous research [54–56], the internal consistency for EOT was unacceptable in the present study (α = .50).

Statistical analyses

All data analyses were conducted using SPSS version 29 (IBM Corporation, Armonk, NY, USA). Group differences were assessed using one-way analysis of variance (ANOVA) for continuous variables and chi-square tests for categorical variables. ANOVA results were reported along with Bonferroni post-hoc tests to control for multiple comparisons. The effect size of group differences was reported using partial η2 for ANOVA.

Binary logistic regression was performed to identify clinical variables (CTQ subtypes, PSS, and TAS scores) as predictors of NSSI engagement in the total sample, controlling for sex (female = 1, male = 0, used as the reference group). Next, for a sex-stratified analysis, binary logistic regression was used within each sex group. NSSI engagement was defined as whether they engaged five or more times in lifetime NSSI (if yes = 1, no = 0). For participants in the NSSI group, multiple regression analyses were performed separately for males and females, with NSSI versatility as the dependent variable and CTQ, PSS, and TAS scores as independent variables. The statistical significance level was set at P < .05.

Results

Sociodemographic characteristics

Among the 731 participants, 498 (68.13%) were females, with a mean age of 22.61 years (SD = 2.67). For sex-specific analysis, we divided participants into four groups: males who engaged in NSSI (n = 124), females who engaged in NSSI (n = 357), males without a history of NSSI or suicide attempts (n = 109), and females without a history of NSSI or suicide attempts (n = 141). Significant age differences were observed across the four groups (F (3, 727) = 3.40, P = .017), with Bonferroni’s post hoc test revealing that males in the NSSI group were older than females in the NSSI group. No significant differences in educational attainment were found among the groups (χ2(9) = 12.84, P = .170), as shown in Table 1. The age of onset of NSSI did not differ between males and females in the NSSI group (F(1, 477) = 0.05, partial η2 = .00, P = .828). However, females reported significantly greater NSSI versatility than males (F(1, 479) = 21.89, partial η2 = .04, P < .001).

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Table 1. Sociodemographic and clinical characteristics (N = 731).

https://doi.org/10.1371/journal.pone.0340384.t001

Comparison of NSSI and control groups: clinical characteristics

Significant group differences were found across all five subtypes of childhood trauma: emotional abuse (F(3, 727) = 66.38, partial η2 = .22, P < .001), physical abuse (F(3, 727) = 21.33, partial η2 = .08, P < .001), sexual abuse (F(3, 727) = 6.94, partial η2 = .03, P < .001), emotional neglect (F(3, 727) = 53.68, partial η2 = .18, P < .001), and physical neglect (F(3, 727) = 19.54, partial η2 = .08, P < .001; Table 1). Bonferroni’s post hoc analyses revealed that for emotional abuse and emotional neglect, both males and females in the NSSI group demonstrated significantly higher levels of emotional abuse and emotional neglect than the control group, and females in the NSSI group reported significantly higher levels than males in the NSSI group. Regarding physical abuse and physical neglect, both males and females in the NSSI group had significantly higher levels than the control group. However, no significant differences were found between males and females in the NSSI group. For sexual abuse, females in the NSSI group reported significantly higher levels of experiences compared to the control group. However, no significant differences were found between NSSI males and NSSI females, nor between NSSI males and the control group.

Significant differences in current perceived stress were also identified among the four groups (F(3, 727) = 59.35, partial η2 = .20, P < .001). Post hoc comparisons indicated that both males and females in the NSSI group demonstrated significantly higher stress levels than those in the control group, and females in the NSSI group reported significantly higher stress levels than males in the NSSI group.

Regarding alexithymia, significant group differences were found (F(3, 727) = 51.38, partial η2 = .18, P < .001). Post hoc analyses showed that both males and females in the NSSI group demonstrated significantly higher alexithymia levels than those in the control group. Females in the NSSI group reported significantly higher alexithymia levels than males in the NSSI group.

Effects of clinical variables on NSSI engagement for each sex group

In the total sample, bivariate logistic regression analyses (see Table 2) revealed that emotional abuse (odds ratio [OR] = 1.10, P = .008), current perceived stress (OR = 1.05, P = .003), and alexithymia (OR = 1.03, P = .001) were all significantly associated with increased odds of NSSI engagement. Sex did not demonstrate a significant association with odds of NSSI engagement (OR = 1.20, P = .343). The overall logistic regression model was statistically significant (χ2(7) = 186.5, P < .001), with Nagelkerke R² indicating that the model explained 30.8% of the variance (Nagelkerke R² = .308).

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Table 2. Bivariate logistic regression analyses on NSSI engagement for all participants (N = 731).

https://doi.org/10.1371/journal.pone.0340384.t002

Separate logistic regression models were conducted for males and females, respectively (Table 3). Among males, only physical abuse emerged as a significant predictor of NSSI engagement. Specifically, males with a history of physical abuse were 1.19 times more likely to engage in NSSI compared to those without such experiences (OR = 1.19, P = .001). The association between current stress and NSSI presence was not significant (OR = 1.05, P = .079), and alexithymia was not a significant predictor in males (OR = 1.02, P = .373). The regression model was significant (χ2(7) = 39.3, P < .001), and explained 20.7% of the variance (Nagelkerke R² = .207).

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Table 3. Sex-stratified bivariate logistic regression analyses on NSSI engagement for all participants (N = 731).

https://doi.org/10.1371/journal.pone.0340384.t003

Among females, emotional abuse was associated with a 1.19-fold risk for engaging in NSSI compared to those without such experiences (OR = 1.19, P < .001). Additionally, each unit increase in current stress was associated with a 5% increase in the odds of NSSI (OR = 1.05, P = .016), and each unit increase in alexithymia was associated with a 4% increase in odds (OR = 1.04, P < .001). This regression model was statistically significant (χ2(7) = 143.9, P < .001), with Nagelkerke R² indicating 36% of the variance explained (Nagelkerke R² = .360).

Severity in the NSSI group

Multiple regression analyses were conducted to investigate predictors of NSSI method versatility among individuals in the NSSI group (Table 4). For the total NSSI sample, emotional abuse (β = .15, t = 2.10, P = .036) and sexual abuse (β = .13, t = 3.00, P = .003) significantly predicted greater method versatility. In addition, current perceived stress (β = .14, t = 2.53, P = .012) and alexithymia (β = .20, t = 3.78, P < .001) were also significant predictors. The overall model was significant (F(7, 473) = 17.15, P < .001, Adjusted R2 = 0.19), explaining 19% of the variance.

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Table 4. Multiple regression analyses on the versatility of NSSI by sex for the NSSI group (n = 481).

https://doi.org/10.1371/journal.pone.0340384.t004

Males engaging in NSSI.

None of the childhood trauma subtypes significantly predicted NSSI versatility in males (all P > .05). Current perceived stress was a significant predictor of NSSI versatility in males (β = .24, t = 2.46, P = .015), while alexithymia was not (P = .101). The regression model was significant (F(7, 116) = 4.20, P < .001), explaining 15% of the variance (Adjusted R2 = 0.15).

Females engaging in NSSI.

Sexual abuse (β = .13, t = 2.54, P = .011) and physical neglect (β = .18, t = 2.69, P = .008) significantly predicted the NSSI versatility in females. Current perceived stress was not a significant predictor (P = .181). In contrast, alexithymia emerged as a significant predictor (β = .20, t = 3.36, P = .001). The regression model was statistically significant (F(7, 349) = 11.28, P < .001, Adjusted R2 = 0.17), explaining 17% of the variance.

Discussion

The current study found that subtypes of childhood maltreatment, current stress, and alexithymia demonstrated distinct, sex-specific associations with both the engagement and severity of NSSI. Specifically, in males, physical abuse emerged as a significant predictor of NSSI engagement, while current stress was uniquely related to greater NSSI method versatility. Conversely, in females, emotion abuse, current stress, and alexithymia were each independently associated with an increased risk of NSSI, while sexual abuse, physical neglect, and alexithymia predicted greater severity. These results critically underscore the existence of sex-specific pathways underpinning NSSI engagement and severity, which indicates that tailoring assessment and intervention strategies to account for these divergent patterns may be required.

Consistent with our hypothesis, subtypes of childhood maltreatment were associated with increased risk of NSSI engagement and severity, but distinct subtypes of maltreatment were uniquely associated with males and females, respectively. Our findings of higher overall childhood maltreatment in the NSSI group compared to controls reinforce the established role of early adversity as a distal risk factor [57,58]. Importantly, our sex-stratified analysis advances the field by revealing sex-specific associations between maltreatment types and NSSI, addressing inconsistencies in prior research [20,23,59]. Although problems regarding statistical power due to differences in sample size should be noted, in line with previous studies [60–62], physical abuse was exclusively related to the NSSI engagement in males. No discernible relationship was found between childhood sexual abuse and the NSSI engagement in either sex, consistent with prior studies reporting weak [63], indirect [20], or absent correlations [23,62,64,65]. However, among females, both sexual abuse and physical neglect were associated with greater NSSI severity. These results align with previous findings in predominantly female samples [43,66], suggesting that while sexual abuse may not directly initiate NSSI, it may exacerbate its severity. Prior work has proposed that emotion dysregulation [67], social avoidance [68], and lack of social supports [69] mediate this association.

Additionally, females engaging in NSSI reported higher levels of emotional abuse and neglect compared to both males engaging in NSSI and controls. Further, among females, emotional abuse was the most salient predictor of NSSI, echoing results from large clinical samples [70] and adolescent research with predominantly female participants (77.7%) [71]. Emotional abuse has been linked to emotion dysregulation [72] and maladaptive cognitive styles such as rumination [73], both of which are known contributors to NSSI in females. These findings suggest that difficulties in emotional processing may serve as mechanisms linking emotional abuse to self-injury in females, given that emotional abuse may influence the maintenance of NSSI in adolescence [74]. Our results underscore the critical importance of disentangling the influence of each subtype of childhood maltreatment. This specificity is crucial, as it suggests that a detailed assessment of maltreatment history is fundamentally required to develop effective and tailored clinical approaches for individuals engaging in NSSI.

With respect to proximal stress, females with NSSI reported higher perceived stress levels than their control counterparts. However, stress was not a significant predictor of NSSI severity, contrary to our hypothesis. In males, by contrast, current stress was associated with NSSI severity, despite not being elevated relative to the control group. These findings are consistent with studies reporting weak associations between stress and NSSI severity [75–77], suggesting that the effect of stress on NSSI may be more closely tied to the exacerbation of existing behaviors rather than the incidence of NSSI. Consistently, a longitudinal study [78] has reported that stressful events significantly increase the risk of NSSI through emotion dysregulation over time, indicating that NSSI is not merely an immediate reaction to stressful events, but rather an outcome of the interplay between stressful experiences and deficits in emotion regulation. Further studies need to elucidate the mechanisms by which current stress is associated with increased NSSI engagement and severity within each sex, particularly by examining the mediating role of emotion dysregulation. Our findings emphasize the importance of considering individual and sex-related differences when assessing the impact of proximal stressors.

As hypothesized, alexithymia also emerged as a robust predictor of both the engagement and severity of NSSI in females, which aligns with previous studies [36–38,79]. Substantial work supports the pathway where childhood maltreatment contributes to the development of alexithymic traits, which in turn mediates the relationship between early adversity and later psychopathology [80]. This consistent finding suggests that, for females, the poor emotional cognition inherent in alexithymia directly increases vulnerability to NSSI, supporting an affect regulation model where self-harm is used to manage poorly understood emotional states [81,82]. For instance, one adolescent study found a significant association between alexithymia and NSSI frequency in girls but not boys [83], a finding confirmed by a recent meta-analysis [39] showing stronger associations in female-only samples. In contrast, the absence of a significant predictive link in our male sample aligns with a subset of previous studies that found inconclusive or non-significant associations between alexithymia and self-harm in males [6,42]. This pattern suggests that, for males, emotional distress leading to NSSI may be mediated by factors other than core alexithymic traits, potentially involving more external motivations or behaviors as a form of expression [82,84]. Therefore, clinicians assessing clients should not rely solely on alexithymia scores, but rather consider sex differences in emotion recognition and processing to determine tailored interventions. These may include emotion regulation skills training for females and exploring the function of externalized behaviors for males [70,85,86].

Despite these crucial findings, several limitations of this research should be noted. First, the current study is constrained by its cross-sectional, retrospective design, which prevents the establishment of causality; thus, longitudinal studies are required to confirm the temporal direction of effects, particularly concerning current stress experiences. Relatedly, the reliance on retrospective self-reported data for childhood maltreatment introduces potential recall bias, and while subjective experiences of adversity may better predict psychopathology [87,88], future research should examine the discrepancies with objective reports. Furthermore, as a cross-sectional investigation, we did not apply explicit criteria for ‘clinical stability’ (e.g., stable medication or absence of an acute crisis) during recruitment, meaning the influence of rapid symptom fluctuation on the reported associations cannot be fully excluded. Also, the lack of information regarding the recency of NSSI behaviors should be addressed as a limitation. Secondly, sample limitations affect the generalizability of the findings. The measure of sex reflects the biological sex assigned at birth and fails to capture the social dimensions of gender [89,90], thereby restricting generalization to individuals whose gender identity differs from their biological sex. Given that sexual and gender minorities are associated with an increased risk of NSSI [91,92], their exclusion further restricts applicability. Additionally, the relatively small sample size of males limits the generalizability of the findings, as the results for the entire NSSI group (n = 481) largely mirrored those for females (n = 357), likely due to the statistical power in the male subsample. Finally, psychometric limitations must be noted: our measure of alexithymia (TAS-20) exhibited limited internal consistency in one subscale (EOT, α = .50). Crucially, the absence of a measure for depressive symptomatology, a known confounder of TAS scores [93–95], means its influence could not be statistically controlled, potentially leading to an overestimation of the unique effect of alexithymia. This measurement limitation also applies to the interpretation of severity: the observed higher NSSI method versatility in females suggests a disparity in the perceived effectiveness of the behavior for achieving NSSI functions [96]. Further research should explicitly investigate these functions and their perceived effectiveness to elucidate these sex-specific mechanisms.

This study established that childhood maltreatment, current stress, and alexithymia contribute to NSSI through qualitatively distinct sex-specific etiological pathways. This underscores the necessity of moving beyond sole risk factor assessment toward a detailed, tailored evaluation of these factors, especially the underlying emotional processing deficits that drive NSSI behaviors, to inform intervention strategies. Specifically, effective interventions should target emotional awareness and expression for females, which may mitigate the effects of emotional abuse and alexithymia, while stress management strategies are recommended for males to address NSSI severity. Further research should prioritize exploring sex-specific trajectories of emotion regulation to elucidate these divergent pathways fully.

Acknowledgments

We thank our participants for their engagement with our study.

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