The tattoos on Zandile Simelane's arms tell a story that most people can’t read. Hidden beneath the delicate blue ink of flowers and butterflies, dull white scars rise, remnants of the time when cutting herself seemed like the only way to express how much she was hurting. (Bhekisisa)
The tattoos on Zandile Simelane’s arms tell a story that most people can’t read. Hidden beneath the delicate blue ink of flowers and butterflies, small white scars rise, remnants of the time when cutting herself seemed like the only way to express how much she was hurting.”I didn’t want to die,” the now 31-year-old told Bhekisisa’s television programme, Health Beat, about her teenage self. “I just needed someone to help me through the pain. A part of me was just screaming — screaming internally to say: ‘What is going on? I don’t know what type of help I need, but help me.’”
For Zandile, the pain began in the years after her mother died, when she was a teen. Her mother, she says, was her whole world and home was her safe place — infused with her mother’s energy, it was welcoming, filled with warmth and bursting with life.
After her funeral, Zandile’s life changed completely. She moved in with her father and her stepmother, with whom she didn’t have much of a relationship. It wasn’t long before she was sent off to boarding school in Durban.
It was there that the troubles really started.
“I’m caught smoking behind the hostel. I’m coming to school drunk,” she recalls. One day, angry and desperate, she pierced her own ear. Soon, she started cutting herself. “Maybe if I cut myself, something will happen,” she remembers thinking. Maybe the pain on the outside would finally match the pain inside. Maybe blood would say what she could not. Maybe someone would notice.
Eventually, they did. A roommate saw that something wasn’t right with Zandile and spoke to a teacher. Soon she was in a psychologist’s office and not long after, a hospital bed. Her father arrived from Eswatini in less than two days. Her pain, she says, was finally heard. And the relief poured out. “I was so grateful about how they responded.”
Unbearable thoughts
For some teens, emotional pain manifests as self-harm — including cutting, burning, hitting, biting, scratching and picking at skin. It’s a coping mechanism psychiatrist Danella Eliasov often sees in her practice near Hillbrow.
“A kid who is cutting themselves or hurting themselves is a distressed kid,” Eliasov told Health Beat. “They’re feeling emotional pain and they’re expressing it almost as physical pain because they’re struggling to express it in words.”
But, she emphasises, self-harm is not suicide. “Self-harm is hurting yourself without the intention to die. You just want to almost hurt yourself … because you’re desperate and don’t know what else to do.”
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which is used globally by mental health professionals, classifies self-harm behaviours that occur more than five days in the past year as non-suicidal self-injury disorder (NSSI-D). But, it also notes that NSSI-D is a “condition requiring further study”, meaning it isn’t a fully-established diagnosis.
Researchers have been trying to get a better sense of its prevalence and how it fits in with the criteria outlined in the DSM-5. A 2015 review of 16 studies in seven countries found roughly 18% of adolescents engage in self-harm at some point in their lives, though only 1.5% to 7% met the criteria of five days in the past year. The studies found it was more likely to occur in girls than boys, while the average age at which self-harm begins is about 13.
But a January 2025 study based in KwaZulu-Natal showed far higher numbers in South Africa. From a sample of 636 students aged 12 to 18, about one in four self-harmed for at least five days in the past year. In a South African Journal of Education study in 2019, more than half of 623 students aged 13 to 24 said they had self-harmed at some point before, and, of those, 62% first self-harmed at age 13 or younger.
Blurred lines
Like Zandile, the teens who are self-harming are doing it to cope with emotional pain or as a way to let others know they are suffering. While it is deliberate, ultimately, the person wants to feel better, not to end their life.
“The problem is, we’ve got a lot in between,” Eliasov says. “We’ve got a lot of people who are kind of in the middle of that. The kind who wouldn’t mind dying; they’re actually just desperate.”
The overlap is real. A 2022 analysis that looked at 37 studies from 23 countries found self-harm is one of the strongest warning signs for eventual suicide; almost a third of people who die by suicide have previously self-harmed.
The number of youths who have attempted suicide is also painfully real. According to the health department, nearly 7 500 children under 18 were treated for suicide attempts at health facilities across the country between April and December 2024.
Compounded trauma
Bomikazi Lupindo, a psychologist and PhD candidate at Oxford University who trained in South African public hospitals, has been studying the mental health impact of violence on children. Her research confirms what she saw working in understaffed, under-resourced public hospitals: there are clear links between childhood adversities, including entrenched South African realities of violence and poverty and mental health difficulties in young adulthood.
“When young people are exposed to negative childhood experiences, it results in either internalising or externalising symptoms,” Lupindo explained to Health Beat. “Externalising would be behavioural problems, substance use. Internalising symptoms would be depression, anxiety, more mood-related issues. Self-harming is often linked to more internalising presentations.”
In Zandile’s case, the trauma was compounded.
“She lost her mother, which was already devastating. Then she was sent to boarding school, which she experienced as a second loss, possibly interpreted as rejection by her father. She’s now even more isolated,” Lupindo says. “That may have resulted in her engaging in self-harming as either a way of regulating her emotions, a way of distracting away from these distressing emotions or just as a way of communicating the level of distress that she had.”
Getting help
Despite the National Mental Health Policy prioritising children and teens, mental healthcare services for this age group are extremely limited.
According to Unicef, six in 10 South African children and youth said they needed mental healthcare. But one in five did not know where to get help, while 18% were afraid of what people would think if they did. “We’ve got to acknowledge the reality — waiting lists are long and the healthcare system is very overburdened,” says Eliasov.
But, she says, help — when caught early — doesn’t always require expensive private therapy.
“You can get the child into a sports programme. Or link them with a healthy adult figure with whom they can connect, who can teach them healthy coping mechanisms.” The key, she says, is teaching teenagers other ways to say “I’m not okay” — writing it down, calling a friend, going for a run, playing music and so on.
For parents, Eliasov advises watching for signs of distress starting in the teenage years, though self-harm can occur in younger children, too. Depression in teenagers, she says, might look like aggression, withdrawal or rudeness rather than the sadness adults typically express.
Researchers say, if you discover your child or student is self-harming, what you do in the first moments matters.
One British study found that teens whose parents “freaked out” and made them promise to stop, often lied to make their parents feel better, then continued self-harming in secret. The panic ended up driving the behaviour underground rather than stopping it. And a 2025 review of 20 studies found extreme parental reactions, whether critical or overly anxious, make young people less likely to disclose their struggles or ask for support.
Another person
Today, Zandile has built a life anchored by routine and self-care.
She wakes early in her sunny flat in Joburg’s northern suburbs just before dawn. She meditates for 10 minutes and then heads for the gym. The days she skips, she notices the difference — memories of her father’s death two years ago surface, old conversations replay or feelings of inadequacy creep in.
She’s finally found what the lost teenager she once was desperately needed; the tattoos covering her scars remain a reminder. “She probably would have done better had someone held her hand,” Zandile says of her younger self, speaking in the third person as if about another person.
In a way, she is.
If you or someone you know is struggling with self-harm or mental health issues, help is available. Call Sadag (South African Depression and Anxiety Group): 0800 567 567.
Learn more about the Johannesburg-based Fight with Insight programme, youth boxing that also offers lessons in resilience, discipline and community, on our Health Beat episode on teen self-harm or on their website.
This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.