Gender, Mental Health and other ramblings

The Weirdly Normal Process of Going to Hospital for Self-Harm

Content warning: self-harm, psych ward admission, suicide attempt mentioned briefly

This is not medical advice. It is based on my experience going to hospital after self-harm plus my understanding of when cuts need medical attention.

I am writing this because a lot of what exists around self-harm and hospital is either too vague to be useful or too sanitised to feel real.

I do not want to write a crisis pamphlet, I want to explain what the process can actually feel like when you are the person sitting in ED after self-harm and provide some guidance to those wondering when their self-harm needs hospital treatment

When I speak of self-harm a lot of the medical treatment (stitches, etc) is specific to my experience of cutting but other aspects of it around how hospital staff treat folks presenting for self-harm are more broadly applicable regardless of method

If you are actively unsafe right now do the boring obvious thing: Go to ED, call emergency services or contact a crisis line.

ā€œWhat brought you in today?ā€

The first strange part is how normal the question is. You get to triage and someone asks what brought you in today. Not as a philosophical question, not as a moral question just the same question they ask everyone else.

Chest pain, fever, broken wrist, stomach pain, self-harm.

You answer and that is usually the first point where it becomes harder to back out and pretend it never happened. Before triage, there is still a fantasy version where you leave. Where you decide you are being dramatic, where you go home and deal with it yourself, where no one else has to know, where it stays private. Once you say it out loud it becomes a hospital problem.

Not necessarily a dramatic one or an emergency where everyone rushes around you. It becomes a process, a nurse asks what happened, how long ago, how serious it is, whether they can see it, whether you are thinking of suicide, and whether you feel like you might hurt yourself again. They check your temperature, oxygen, and blood pressure. Then you go to reception and give your details.

That is one of the weirdest parts of hospital after self-harm. Something that felt private, ugly, emotional, and hard to explain gets turned into questions, observations, paperwork, and waiting. It does not stop being emotional. It just also becomes admin.

The hospital does not receive your self-harm as a confession. It receives it as a problem to process.

When it becomes something you cannot safely handle

I do not go to hospital because I suddenly feel ready to have a large emotional conversation with a crisis team, I go because plainly speaking the wound is something I cannot manage myself.

Self-harm is one thing, but I didn't sign up for an infection, bleeding so heavily it ruins my clothes or showering for weeks with an open wound. At some point the question stops being ā€œwhy did I do this?ā€ and becomes ā€œcan I safely deal with the physical consequences of this?ā€

For me, hospital becomes the answer when it has crossed from a private act into a medical and life problem. That does not mean I am proud of it, it does not mean I want attention or I feel like I deserve help. It means the wound needs care

A wound may need hospital or urgent care if:

You do not need to prove you are suffering enough, you do not need to be at the exact correct level of distressed. If the wound needs care, the wound needs care

Triage is where private shame becomes a script

Triage can vary a lot between hospitals, sometimes it is in a slightly private area other times you are only a few metres away from other people in the waiting room and it feels like everyone can hear enough to know something is wrong

They ask for your details, what happened, how long ago and if they can see it (if it is already securely bandaged you can let them know and show them a photo instead). They will probably ask if you are currently suicidal or feel like hurting yourself again.

Triage will assign you a category based on how urgent you need treatment, this will impact your waiting time and it's ok to ask politely so you have an expectation for how long you'll wait

I'd encourage checking with your local health authority on which system they use, expected wait times and how self-harm is typically rated/ranked

After that you'll be asked to confirm your details with reception and then you just sit in the waiting room feeling like you've created a tense situation just by existing

You can end up monitoring your own body language like you are trying to pass an exam no one explained. I have often worried about being seen as attention-seeking, a waste of resources, stupid, unsafe, or someone who hurt themselves over something too dumb to justify the amount of hospital time now being spent on it.

That is one of the quietly awful parts. You are not only dealing with what happened but how people interpret that

A small note if you are trans

This is not a post only for trans people. Most of the hospital process is the same regardless: triage, waiting, wound care, risk questions, paperwork, discharge, maybe admission.

But being trans adds a few extra ways for the hospital to make you feel exposed.

The first one is your name (assuming you haven't updated it). If you are visibly trans, a triage nurse may ask what name you use or whether there is another name you prefer. When this is done well, it can be quiet and practical. They ask and add a note but some staff may not use it (either from malice or not reading the note).

If they do not ask you can say "Could you add a note to my case/file that I prefer to be called [NAME]"

Even if you do this it doesn't mean the whole system will obey it.

Your legal name will still appear on your wristband, printed labels, discharge paperwork, medication charts and the screen staff are reading from. You may still hear the wrong name called in the waiting room and have to stand up anyway. A person might be kind while the system is not. That split can feel very strange, one part of the hospital sees you correctly but another part keeps dragging the legal version of you back into the room.

There is also the question of gendered spaces. In ED this may not matter much because you are mostly in waiting rooms, curtained bays or treatment areas. In a psych ward or if you're admitted to the hospital for treatment it can matter more.

The general guidance is that hospitals should put you in rooms/areas that align with your self-identified gender but some hospitals will put you in a seperate room just to avoid the discomfort. If someone raises an issue about you being trans the general policy is also that the person raising the complaint should be moved not the trans individual.

The other thing to expect is that some clinicians may over-focus on hormones or transition when you are talking about mental-health. Dysphoria, passing, social stress, family stuff, legal documents and being visibly trans in public can all affect mental health but sometimes it feels like they reach for ā€œhormonesā€ because it is the most obvious trans-shaped explanation in the room.

You can come in because of a specific crisis, a relationship issue, shame, work stress, loneliness, or something completely unrelated, and still feel the conversation drifting toward whether your hormones are making you unstable

That can be frustrating because it makes you feel simplified. You are not just a medication regime with legs. You are a person who self-harmed for reasons that may or may not have anything to do with being trans.

A better clinician will ask about transition without making it the whole explanation. They might ask whether dysphoria is part of what happened, whether you feel safe at home, whether people in your life use the right name, whether your documents are a problem, whether hormones have changed recently, and whether you have gender-affirming support. Those are fair questions.

A worse clinician may treat being trans as the problem before they have understood anything else.

The practical advice is boring but useful: ā€œMy hormone dose has been stable unchanged since [DATE] and I do not think that is what this is aboutā€

The main thing is that being trans can make hospital feel like you are being assessed twice. Once for the self-harm and once for how legible or complicated your identity is to the system.

Waiting is often boring, which makes it stranger

After triage and confirming your details with reception you'll sit in the general waiting room

Plastic chair, phone, one headphone in so you can hear your name. Surrounded by other people coughing, bleeding, sleeping, complaining, trying to keep children calm.

The emotional peak may already be over. You may be calmer now, you may be sitting there thinking ā€œI am too normal now. I have made this look fakeā€

That is something people who have never self-harmed may not understand. You can be in a serious situation and still mostly be scrolling your phone, you can need stitches and still be bored, you can be at risk and still be polite. You can be ashamed and still remember to keep one ear free so you do not miss your name

The crisis can be over before the hospital process has even started

Medical treatment: the wound becomes a task

Eventually you get called in and a doctor will take you to a curtained or closed-off area of ED and ask you to sit or lie on the bed

There may be another brief conversation before they decide what to do with the wound. Why did you do it? How did you do it? Do you want to speak to mental health? Are you safe?

In my experience, the practical sequence is often something like:

Sometimes the wound is the only thing they really focus on and othertimes mental health becomes a bigger part of it. Often it depends on who is working, how busy they are, how distressed you seem and whether they think you are safe to leave

The body part of it can feel worse than people expect. Not necessarily because of pain but because a stranger is handling proof of something you are ashamed of. You may be touched somewhere you cannot easily see. You have to let someone else look closely at something you did privately.

It's totally ok to ask for a blanket or towel to cover up and preserve modesty so you're not sitting in your underwear as they examine your leg, etc

I have asked to sit up during treatment because lying down while someone works on a part of my body I cannot see makes me uncomfortable. Some staff accept that but others push back in a way that feels like they think they know your body better than you do.

I have also been asked once whether I wanted a witness or another nurse present while a doctor treated me. It is not something I have been asked every time but the fact it was offered at all suggests it is a normal enough thing to ask for

If you are uncomfortable, you can ask:

You might not always get exactly what you want but you are allowed to ask

Staff are people inside a system

Staff are kind, cold, tired or procedural. Some are careless in ways that stick but most are not giving a lecture. Most are trying to get through their shift and keep the department moving

That can be fine. Robotic is not always cruel, it's just the machine moving

But the difference between cold process and small kindness can be enormous. I remember a nurse complimenting my shoes at the start of an interaction which I know sounds stupid and tiny (It is stupid and tiny) but it also changed how the rest of the interaction felt. When she later asked about safety, the wound and what happened it felt less like someone going through a checklist and more like a person asking

I remember staff using the right name, I remember staff accepting that I did not want local anesthetic without turning it into a power struggle. I remember a nurse offering to pick up food from downstairs because the surgery I needed after a particularly bad case of self-harm had been rescheduled and I missed the hospital dinner

Those moments do not fix anything but they do make you feel less like a problem in a bay

The opposite also happens. Years ago I overheard a doctor say something like ā€œDoesnā€™t look like this one is attention seekingā€ when he thought I could not hear him. That sentence did damage, not because he called me attention-seeking directly but because he revealed the category existed in his head. He revealed that this was something being judged, that injuries were being sorted into ā€œattention-seekingā€ and ā€œnot attention-seekingā€

That made me want to self-harm more dangerously so I would not be put in the wrong category.

That is the kind of thing staff need to understand, a careless sentence can become part of the next injury

I have also had a doctor insist I had BPD because I had come in repeatedly. That spiralled me badly, it took time before I felt comfortable going back to hospital. The point is not that BPD is bad but that being labelled quickly, wrongly or carelessly can make people avoid care. It can make them think the hospital has decided their worth

ā€œDo you want to speak to mental health?ā€

At some point the triage nurse or the doctor may ask if you want to speak to mental health. It's usually fine to say no

If you are calm, medically straightforward, not currently suicidal and staff believe you are safe enough to leave you may not have to speak to mental health. But depending on your level of distress and suicide risk you may not get much choice.

The mental health team may ask:

This is where honesty becomes complicated, a pamphlet would say "always be honest" but honesty has consequences and hiding things does too

Saying ā€œI do not want to answer thatā€ also has consequences because the person assessing you will interpret it.

Sometimes people minimize because they need to get home. Admission could risk their job, they have pets to take care of, they cannot afford the disruption, etc

But if you understate everything so you can leave faster you may get exactly what you asked for, being left alone with the same risk that brought you in

There is no clean answer here, you do not need to perform the perfect patient. You do need to understand what question they are trying to answer most of the time, the question underneath everything is "are you safe enough to go home tonight?"

Being remembered

There is a specific shame in being remembered at hospital for self-harm.

The shame is not just ā€œI am hereā€ it's that ā€œI have been here enough times that this place knows a version of me I'm ashamed ofā€ That can make you feel like you are becoming recognisable only through failure. It can make you worry they have already decided what kind of patient you are

A frequent flier, attention-seeking, difficult

It can also make you feel pressure to become extra polite and easy so you don't get remembered badly. You do not want to create more work or confirm their worst assumption

But needing care more than once does not mean you are not allowed to need care again. Even if you were there last month. Even if someone recognises you. Even if you are embarrassed. Even if you are calm now. Even if part of you thinks you should be banned from needing help because you have needed it too many times.

The wound still needs what it needs.

Discharge is often anticlimactic

If they discharge you from ED, it will be very administrative. You'll get a discharge summary, wound-care instructions, antibiotics sometimes, instructions for stitch removal, crisis numbers and advice to follow up with primary health or mental health service.

And then you leave.

Sometimes discharge feels like relief. Sometimes it feels like abandonment. Sometimes it feels like you fooled them. Sometimes it feels like they did not care. Sometimes it is just numbness. You walk out with a dressing, maybe stitches, maybe antibiotics, maybe a plan, maybe nothing that feels useful.

Discharge does not mean the problem is solved. It means the hospital has decided your problem can leave.

When you get admitted

Not everyone who goes to hospital for self-harm gets admitted to a psych ward. Most people will not be admitted just because they self-harmed.

Admission becomes more likely if staff think you are not safe to leave, if there is serious suicide risk, if you are very distressed, if there are concerns about your mental state, or if the situation is otherwise unsafe.

My own psych ward experience was after a suicide attempt not just a self-harm presentation but admission after self-harm can happen.

The simplest way I can explain it is this: ED is where they work out what needs to happen now. The psych ward is where you go if leaving is considered too unsafe.

The psych ward is not what people imagine

People imagine psych wards in extremes, either it is a horror movie full of screaming or it is a healing retreat where someone finally takes over and fixes the problem

In my experience it is neither. It is mostly discomfort, rules, boredom, observation, other peopleā€™s distress and not being the person who decides when you can leave

You may wait in hospital for a psych bed to open. Your belongings will be checked and anything sharp or usable for self-harm will be removed including things like chargers and razors, apart from belts you'll be able to keep your own clothes and phone access may be controlled

In my case I could use my phone in the common area which helped

The day can be extremely structured and extremely empty at the same time

Depending on your risk rating or leave status you may not be allowed to leave the ward at all. Later you might be allowed escorted leave and even later maybe unescorted leave. You start with less freedom and earn more through time and assessment

That is one of the hardest parts, you may want to leave almost immediately because the ward is so uncomfortable.

Am I eating too much? not eating enough? Sleeping too much, not sleeping, talking, not talking, laughing, sitting alone. Everything can start to feel diagnostic like a million small things that don't matter to you can currently impact your life in unexpected way

I remember feeling like the most ā€œnormalā€ person there which is not necessarily fair or kind to the other patients but it is honestly how it felt. Other people were dealing with visible, loud, frightening or intrusive symptoms that can be hard to be around. It does not make them horror props or bad people but it does mean the ward can be deeply uncomfortable

I remember at one moment playing a card game with another patient and he wouldn't stop talking about his disturbing sexual fantasies, when I reported it to staff they just said "Yeah we know, that's why he's here"

The psych ward is not constant therapy, it is not where your life gets fixed it is where the system keeps you until it believes you are safe enough to leave

For people who have never self-harmed

Do not turn the person into a horror story or an object to pity. Do not decide whether the reason was good enough.

Self-harm can be a coping strategy. It's dangerous, damaging and frighteening but it's still a coping strategy. The thing that triggered it may look minor from the outside but that does not mean the pain was minor, you may be seeing the final straw and mistaking it for the whole load

I once self-harmed because I overslept and was late to feeding my cats which sounds silly but in my head it was the final confirmation that I'm destined to fail and let down even those I care about the most

I have had more obvious pity for testicular torsion than for self-harm. That is funny in the bleakest possible way but it also says something real. Self-inflicted injury changes the social meaning of pain, people become less sure how much sympathy they are allowed to have

Calm does not mean fine, polite does not mean fine, scrolling a phone does not mean fine. A self-inflicted wound is still a wound and the fact that someone did it to themselves does not make the medical need fake. It does not mean pain stops counting, it does not mean they deserve worse care than someone who got hurt by accident

You do not have to understand self-harm completely to avoid being stupid about it. Start here:

What I wish I knew

The process can be cold and still useful, staff can be imperfect without the whole hospital being useless. One bad doctor does not mean you should never seek care again and being calm does not mean you wasted their time.

The hospital will not decide whether your pain was justified. Mostly it will decide what the wound needs and whether you can leave. That can feel cold because it is cold but it can also be enough to stop one night from becoming worse

#Essays