Images on the internet: A systematic review of studies on the impact of on-line sharing and viewing of self-harm related videos and photographs in young people. (Preprint)
BACKGROUND Given recent moves to remove or blur self-harm imagery or content posted online, it is important to understand the impact on young people of posting, viewing and reposting self-harm images. OBJECTIVE The aim of this study was to systematically review research related to the emotional and behavioural impact on children and young people of viewing or sharing self-harm related videos or images online. METHODS We searched databases (including EMBASE, Psychinfo and MEDLINE) from January 1991 to February 2019. Search terms were categorised into: internet use; images non-specific and specific to the internet; self-harm and suicide. Stepwise screening against specified criteria and data extraction were completed by two independent reviewers. Eligible articles were quality assessed and a narrative synthesis conducted. RESULTS 19 independent studies (20 articles) were included. Four studies focused on images, ten (11 articles) on videos and five on both. There were four quantitative, nine qualitative and seven mixed methods articles. Eleven articles were rated as high quality. There has been an increase in graphic self-harm imagery over time. Potentially harmful content congregated on platforms with little moderation, anonymity and easy searches for images. A range of reactions and intentions were reported in relation to posting or viewing images of self-harm: from empathy, a sense of solidarity and the use of images to give or receive help; to potentially harmful ones suggesting new methods, normalisation and exacerbation of self-harm. Viewing images as an alternative to self-harm or a creative outlet were regarded in two studies to be positive impacts. Reactions of anger, hostility and ambivalence were reported. There was some evidence of a role of imitation and reinforcement, driven in part, by numbers of comments and wound severity but this was not supported by time series analyses. CONCLUSIONS While the results of this review support concerns related to safety and exacerbation of self-harm through viewing images of self-harm, the potential for positive impacts should not be underestimated. Future research should evaluate the effectiveness and any potential harms of current posting restrictions, incorporate user perspectives and develop recovery-oriented content. Clinicians assessing distressed young people should ask about internet use, including access to self-harm images, as part of their assessment.