Self harm is the intentional direct injury of one's own body without suicidal intention. It is regarded as a non-verbal form of communication used to express suffering. Self injury can also be understood as a way of releasing feelings of anger, rage or emotional pain, since the feeling of physical pain has a mildly tranquilising effect^1,2. A number of authors believe that it is a call for attention and help by publicly showing internal suffering¹. However, some self-injuries are committed for personal benefit and efforts are made to conceal them³.

Self-harm is much more common amongst adolescents and in the prison setting. The most common forms amongst this age group are cutting the skin, hitting oneself, burns, pulling out one's own hair, pricking, scratching and pinching¹. Many types of self-injuries have been described in the prison setting, such as incised wounds or chinazos, especially on the left arm, the insertion of metal objects (clips, nails, screws, etc.), ingesting foreign objects, especially batteries and razor blades, punching the wall, most frequently with the right hand, swallowing bleach or detergents, head-butting the wall, burning oneself with cigarettes, etc.^2,4,5.

Stitching one's own lips is a very rare type of self-harm, but it has been described previously in prisons. Vera-Remartínez et al. show images of two cases⁴. One of the cases attempted a complete suture of the mouth with one piece of sewing thread, with three perforations in the upper lip and two in the lower. The other was only one stitch with a thick thread in the middle of the lips, with just one perforation in the upper and lower lips. In this particular case the inmate could smoke and drink on either side of the mouth. In both case, the reason for the self injury was the need to reassert a hunger strike⁴.

This article presents a case of self harm consisting of a complete suture of the lips (Figures 1 and 2) that looks almost professional, carried out with a sterile hypodermic needle secretly obtained from the medical services and black sewing yarn that looks very similar to 3/0 surgical suture thread. The tip of the needle was used to insert the thread through 16 perforations in the upper lip and 17 in the lower until the mouth was completely closed, making it impossible to talk, eat, drink or smoke.

Figure 1.  Complete suture of lips. 

Figure 2.  Image of the suture four hours after completion. 

The self-injury was carried out four hours before being detected by prison officers, who immediately transferred the patient to the medical services. As he was unable to talk, he wrote his main claim on a piece of paper: “I want to speak to my lawyer”, and initially refused to allow us to remove the suture. After applying the relevant approach, the relative lack of resistance he showed was surprising as he voluntarily consented to have it removed. He was asked if photographs could be taken and he nodded his consent, with a look of satisfaction on his face. After the suture was removed, he signed a written consent to authorise diffusion of the images in the scientific media.

The case consists of an internee from Morocco, of 20 years of age, with a diagnosis of borderline personality disorder and a background of drug abuse. He explained that the idea of sewing up his mouth occurred to him and that he had not seen any similar type of self injury amongst the other internees. His aim was not to go on hunger strike but rather to express his displeasure in a way that would attract attention. He felt unjustly treated by the legal system, considered that the grounds for the treatment he received were unfair and that he had not been given the option of speaking with his lawyer often enough or as quickly as he wanted.

Borderline personality disorder has been found to be one of the most common of the many psychological and psychiatric disorders associated with self injury¹.