An exploratory study of women prisoners’ attitudes towards their self-harm and the use of medical skin camouflage

ABSTRACT Self-harm is a growing problem in UK prisons with women self-harming more than men. Self-harm can leave permanent scarring. Research on scarring suggests that living with scars can lead to psychological difficulties; however, there is little research on the specific effects of self-harm scars. Medical skin camouflage (MSC) can be used to cover numerous skin conditions. The use of MSC for women in prison with self-harm scars has not been examined previously. A focus group involving 10 women prisoners aimed to (1) explore feelings about self-harm scars, (2) examine effects that scars have on life in prison and (3) examine thoughts on using MSC in prison. This group formed part of a larger project designed to test the feasibility and acceptability of MSC for women who self-harm in prison. A topic guide was created with two service user researchers with experience of self-harm in prison. The results have been divided into three themes: (1) feelings about self-harm scars, (2) covering self-harm scars and (3) attitudes towards MSC. Our findings indicate that women in prison tend to feel embarrassed and self-conscious about their scars, and the presence of scars affects their relationships within prison. The women were enthusiastic about MSC, suggesting that it has the potential to affect women’s well-being and ability to engage with others.


Introduction
Self-harm is one of the most important current public health concerns for prisons, as highlighted in the recent Ministry of Justice white paper, 'Prison Safety and Reform' (Ministry of Justice, 2016a). Rates of self-harm are higher in women's prisons with 2031 incidents per 1000 women compared to 501 per 1000 men (Ministry of Justice, 2017b). High self-harm rates is a longstanding problem within the women's prison estate, with women in prison far more likely to die by suicide or to self-harm than women in the community (Home Office, 2007;Shaw, Appleby, & Baker, 2003;Shaw, Baker, Hunt, Moloney, & Appleby, 2004).
Self-harm is a complex behaviour associated with acute psychological distress and increased suicide risk (Hawton, Linsell, Adeniji, Sariaslan, & Fazel, 2014;Marzano, Fazel, Rivlin, & Hawton, 2010). In the criminal justice context, self-harm is defined as 'any act where a prisoner deliberately harms themselves, irrespective of the method, intent or severity of any injury.' (Ministry of Justice, 2017a, p.7). The most common methods in women's prisons are cutting/scratching followed by strangulation (Hawton et al., 2014). For the purpose of this paper, we are interested in any form of selfharm which results in scarring.
Self-harm can serve many, complex purposes for those who do it. Motz (2016) notes that it can allow people to express internal distress to the outside world without having to vocalise issues; it can provide relief from stress and pain and it can help people gain a sense of control in an otherwise chaotic environment. Many women who are in prison have experienced early childhood adversity, including child sexual abuse (Ministry of Justice, 2012). One of the motivations that women may have to self-harm is to express early traumatic experiences through and on the body, a kind of embodiment of a trauma (Motz, 2016). This embodiment means that often women are left with visible scars which have complex meanings. Some research has suggested that a greater number of scars from non-suicidal self-injury can be associated with higher levels of current suicide ideation (Burke, Hamilton, Cohen, Stange & Alloy, 2016).
Previous research on the effects of scarring has focussed on scars which are not the result of self-harm, such as burn scars caused by an accident with fire or acid. This research has identified long-term psychosocial effects, including reduced social interaction, increased social anxiety and reduced quality of life (Brown, Linehan, Comtois, Murray, & Chapman, 2009;Van Loey & Van Son, 2003). Living with disfigurement has been shown to have a negative effect on self-esteem, self-confidence, interpersonal relationships, activities of daily living and ultimately recovery in both genders (Krishna, 2009). Women with self-harm scarring may experience similar problems which could be worsened by any guilt and shame they might feel because their injuries are self-inflicted (Lewis & Mehrabkhani, 2016).
Medical skin camouflage (MSC) uses British National Formulary-listed preparations to reduce the visibility of scarring or disfigurement (McMichael, 2012). The products include creams and powders that are waterproof, opaque and allow adherence to textured skin, including scarred areas. MSC may be an important intervention from a public health perspective since it is safe and relatively inexpensive with the potential for costeffective, sustainable delivery within the UK prison estate. MSC could be used both in conjunction with and after psychological treatment for people who self-harm and, in this way, may continue to provide a method to improve quality of life after psychological treatment has ended.
Only, a handful of published studies have evaluated the psychological effects of MSC. These were all in relation to scars caused by dermatological diseases or accidental burns. They report significant psychological benefit and improved social relationships (Hayashi et al., 2005;Levy & Emer, 2012;Tanioka, Yamamoto, Kato, & Miyachi, 2010). Although benefits from MSC have been reported, it has also been noted that some people can feel a further sense of inadequacy and embarrassment from having to resort to using such means to cover up (Kent, 2000). Before an MSC intervention is tested with women in prison, it is important to explore their perspectives on the intervention.
The current study has been developed in collaboration with staff from five Boroughs Partnership NHS Foundation Trust, who recently piloted an innovative MSC service for adolescents who self-harm (Ranote, 2016). The 6-month, open-label, unrandomised pilot demonstrated a clinically significant improvement in the self-confidence of service users, as well as increased well-being and ability to partake in social activities (Ranote, 2016). To our knowledge, this was the first time that MSC had been evaluated in a mental health service for self-harm (Ranote, 2016).
Although self-harm is a prevalent issue within female prisons, no research has focused on the effects of self-harm scarring on women's well-being in this setting and none has looked at the use of MSC. The current project forms part of a programme of research designed to develop an evidence base for a recovery stepped-care pathway to be implemented with women in prison settings.

Aims and research
This qualitative research forms part of a larger project examining the feasibility and acceptability of the use of MSC for women who self-harm in prisons. The focus group, reported in this paper, was undertaken as part of the trial preparation. The aims of the group were • To explore women's feelings about their scars; • to examine how their scars affect their life in prison; and • to examine their thoughts on MSC.

Design
This exploratory focus group was embedded in a feasibility and acceptability pilot of MSC for women who self-harm in prison. A focus group design was chosen as it can elicit rich data on a complex topic through participants discussing, challenging and qualifying their views (Willig, 2008). A focus group also allows participants to use their own language and bring up their own issues relating to a topic, which was deemed particularly useful when exploring selfharm and the acceptability of MSC in this prison setting (Wilkinson, 1998).
Women prisoners participated in the group, which took place in the Safer Custody suite in one prison in the north-west region. Safer Custody are the teams within prisons responsible for the assessment and management of prisoners who are at risk of self-harming or suicide. To avoid overburdening the women, the focus group was completed over two meetings, lasting 60 and 20 min, respectively.

Sample
Participants were female prisoners currently in a prison on remand or sentenced in the northwest of England. They were eligible to be included in the focus group if they had self-harmed in the past or were currently selfharming and had self-harm scarring. All participants were 18 years or older and able to give written informed consent. Ethnicity of the participants was not recorded. A purposive sampling technique was used. Leaflets and information sheets on the research were shared with women prisoners by the local collaborator, a Safer Custody staff member. Interested women informed the local collaborator that they wanted to take part in the group. Women who would pose a high risk of physical harm to the researchers or who were too distressed or unwell, e.g. currently experiencing severe psychosis, to participate in a group discussion were excluded from participation. The initial aim was to get approximately 6-10 participants in each group. A total of 10 participants took part in the two groups, with 9 people taking part in the first group and 4 in the second group.

Focus group structure
A topic guide was developed and refined following discussion with two service user researchers with experience of self-harm in prison who ensured that questions were comprehensible and sensitive to women prisoners' needs. The guide was designed to gather information on specific topics as well as stimulate general discussion on the effects of selfharm scarring. The guide included questions on the women's feelings about their scars, how scars had affected their life in general and in prison and their thoughts on the use of MSC. The women were encouraged to discuss what would influence their well-being and their recovery from self-harm.

Focus group
A focus group was then arranged with the research team in the Safer Custody rooms within the prison. The information sheet was read to the women at the start of the group and they had the opportunity to ask questions before providing written consent to participate. At the start of the group, the facilitators established ground rules concerning respect for other women in the group and maintaining confidentiality. The women were informed that they could leave the group at any time and that the local collaborator, who sat in on the group, could provide access to support after the group if they were distressed.
The aim was for 6-10 women to participate in the group. Nine women attended the first meeting and four women attended the second; one of these women did not attend the first meeting. One woman chose to leave the first meeting before it ended as she was finding it difficult to talk about her experiences in a group. The local collaborator reported to the researchers that no women required additional support following either meetings. Individual contributions were not identified from separate participants. Some participants were more engaged than others within the group but no in-depth information on group dynamics was recorded. Most participants did make a contribution.

Reflexivity
The researchers who facilitated the focus groups were both experienced in working with women who self-harm. Although they moderated the group, every attempt was made to allow the participants talk amongst themselves without interruption. A member of Safer Custody was also present for the groups as a safety precaution; however, he did not participate in the group. The member of prison staff was someone within the prison who had a supportive role and the women appeared comfortable talking about personal issues in his presence.

Analysis
With permission, the focus groups were recorded and transcribed by the research team. The recordings were transcribed verbatim. The research assistant and one service user researcher independently analysed the transcripts using NVivo 11. A thematic analysis approach was undertaken as the aim was to gather knowledge about the participants' experiences and attitudes (Kelly, 2010). Transcripts were read by the two researchers, and preliminary codes and a coding frame were developed. Categories were then assigned to the text and sorted into themes. All coding and categorisation used 'low inference descriptors' (Seale, 1999) to ensure that the themes closely reflected the data. During coding, the data were searched to see if there were any 'negative instances' which contradicted the main conclusions (Seale, 1999). Data saturation may not have been reached as it was an exploratory study that formed part of a larger project covering a topic and sample not previously researched. Therefore, a smaller sample size was obtained than if it was a stand-alone piece of research. A second researcher then subjected all themes to constant comparison (Glaser & Strauss, 1967) and examined for goodness of fit until a final set of key themes was identified.

Rigour
To ensure trustworthiness and to protect against bias (Gbrich, 1999), academic peer review was undertaken by one independent researcher who analysed the raw data. The independent researcher identified highly similar themes to the research team.

Ethical approval
Ethical approval was granted by the North East -York Research Ethics Committee (REC reference: 16/NE/0030) with site-specific approval from Greater Manchester Mental Health NHS Foundation Trust. The National Offender Management Service and the prison governor also approved the research.

Results
The results have been divided into three overarching themes: feelings about self-harm scars, covering self-harm scars and attitudes towards MSC. No individual participants were identified on the recordings or as part of the analysis; so, individual quotes are not identifiable.

Feelings about self-harm scars
Participants discussed their feelings about their self-harm scars. A number of women said they felt embarrassed or lacked confidence because of their scars, particularly around people they did not know: It embarrasses you especially when there's a few other people about they can blatantly see them, but it's an elephant in the room isn't it, and sometimes when I meet people who I've never met before and they'll be having a conversation with me talking away and then you'll look down . . . and you can see the shock in their faces and like they lose their train of thought and it's embarrassing.
I lack confidence in my body because obviously the scars are there forever, for life. . ..
One participant said that her scars did not bother her, although most women stated that they wished they could take their scars away and liked it when their scars became less obvious: I'd love to wake up and for them to just not be there because they've been there for that long, it's just horrible I know over time the scars go white and when they are not as red and they don't stand out as much and I, I feel better when they're not new. When they're like all red and nasty then they stand out.
Several participants expressed how the scars acted as a reminder of bad times in their life. One of the women indicated that she did not like people asking about the scars as she felt it was obvious what had happened: when you look at them it reminds you of the time when you did it and why you did it and you know, how you felt when you did it All these got done at the same time so when I see them I just think I never want to go back to that place ever again and that just reminds me that I don't ever want to put myself in those situations to try not to end up like that again. But it's shit when people ask about them because its blatantly obvious Participants discussed how their feelings about their scars differed in the prison environment. Some women said that being in prison had made their self-harm worse as they felt trapped, frustrated or angry. However, with regards to their scars, participants felt less embarrassed around other women in prison as self-harm scarring was more common. Participants said that being someone who self-harms was not as bad in prison as in the community because it is the 'norm' in this environment: I'm a lot more embarrassed about them in the community because it's not the norm, I know it sounds mad but it's the norm in jail.
Participants were concerned about being seen as attention-seeking or 'crazy' because of their scars, with some participants mentioning their own experiences of being judged or called names: Girls that don't self-harm, say there's a girl that does it and people who don't self-harm are not arsed to be honest they'll just look at girls [that do] and think she's just doing it for attention.
Yeah because they'll just think that you're crazy straight away because it's not really the norm is it to do that so if somebody sees that they are going be like, 'ooo look what they've done'.
It's like me, I get called, 'a weirdo' because I cut myself.
Some participants expressed concerns about being prematurely judged because of their scars, whilst others described how they felt when people commented or asked about them: they're going to think there's something not right with me if I've done all this so its straightaway painting a bad picture of me before somebody gets to know you People you don't even know -'oh my god why do you do that?'well I'm not going to go into a conversation why I've done every single scar that's on my arm but thanks for asking you prickthat's how I feel Some participants described how they had experienced negative reactions from prison staff because of their scars: Others described staff as being 'supportive' and outlined situations where other women had helped them: Same for me last night, I got caught sat in on the table eating me dinner, the girls knew something was wrong and one of them picked up that I had something in my room and she did the right thingshe got in the room with the officer took it out, I came back in my room and it's gone. I'm thinking 'what the hell you know?' but you know that girl, kind of saved me life because it was a ligature it wasn't just self-harm, it was the worst thing that you can do ligature.

Covering self-harm scars
When discussing their thoughts on covering up their scars, participants' responses reflected their concerns or perceptions about the attitudes of others. When participants were asked about situations where they would want to cover their scars, the majority focused on social situations. Participants were particularly concerned about showing scars to their family during visits, especially if they had not talked about their self-harm with them: The only reason I hide it from my gran and grandad is just, and my family, it's because I don't want to upset them, to know why I've done it or the pain that I'm feeling I don't want to put it on anyone else. That's the only reason I hide it and they wouldn't understand.
I don't speak to anybody, that's what I mean my family doesn't know or understand, I've never told anybody about my stuff like that, that's why I need to hide it. Some participants expressed particular concerns about exposing their scars to younger family members, in case they upset them or encouraged them to try self-harming: Yeah that's another thing, like my ex's daughter she used to say to me, because obviously kids see it, and she used to ask me about it and stuffyou just have to try and come up with some lies or something. Then obviously I don't want her to get it in her head that it's good to have scars.
In contrast, one woman described feeling more comfortable around her family: Participants felt that they had to cover their scars in social situations for a number of reasons. They were mindful of the effects their scars might have on others who could find them shocking or upsetting: If they're open I feel uncomfortable going anywhere because that's when you realise, you don't realise when you're doing it, but when you've done it there's people in here that have never ever seen that they've never, do you understand what I mean? So I've, I've seen people cry at my cuts before. Because it's not, it's not the norm for them whereas it is for me. I know we say it's the norm in here but there is some people in here where it's absolutely shocking to the point where they get upset about it.
And a lot of women are quite distressed by it. . .. The majority of the discussion focused on how other people in the prison might view them once they knew that they self-harmed. As a response to the perceived effect of the scars on others, participants already used a range of strategies to avoid revealing their scars. Several participants described how their scars affected the clothes they wore in certain situations: if I was meeting somebody, going to date [with] somebody I'd try and wear a shirt, a long sleeve shirt but I'm not, me I always like wearing shorts, I hate clothes I feel trapped but I feel like I have to cover up because I feel like if somebody sees it and they've never met me before and they see all this they are going to think there's something not right with me if I've done all this so its straightaway painting a bad picture of me before somebody gets to know you.
A couple of the participants had tried to cover their scars with ordinary makeup but found that it did not give good coverage: I've tried to put make-up on my [scars] just normal make-up on my scars as well before. . ..

It's not very good with normal make-up because it doesn't stay on
Another participant had tattooed over her scars, although she had subsequently cut over the tattoo: That tattoo there was to cover up some scarsobviously now I've cut it up again Some participants expressed frustration and anger about having to wear clothes to cover up their scars, especially in hot weather. Some responses reflected their views that they should not have to cover up, as people should change their attitudes towards self-harm: it is horrible trying to find, you might just want to put a f***ing vest on and you're like, 'I can't because I'm seeing this person', so you've got to try and fit your whole outfit round your fricking scars Yeah because other times you forget, don't you? Because you're so used to it you forget and then someonedo you know what I'll be honest with you, I think we shouldn't have to cover up, people should have more awareness around it However, participants also said that covering their scars could be helpful in terms of stopping them from being constantly conscious of their scars in social situations and from feeling paranoid about others looking at them: to stop having to be, to think about it all the time and be, I don't really think about them but if I know someone's looking straight away and you think your arms are showing and you'll move them and hide them and then you think they know, I know that they've been looking and it gets awkward doesn't it?
And not being paranoidare they looking at my scars?. . .

Attitudes towards MSC
The participants felt that if they had the MSC on, then they would not be as conscious of their scars and would not have to adjust their behaviour to ensure that others do not see them: but obviously if you had the makeup and you felt confident that you couldn't really see them then it's another less thing to worry about I even try to sit and angle my arms in certain ways just so you can't see them Obviously it will help your confidence a bit because you wouldn't have to be worrying, thinking are they looking at my scars or whatever Participants also felt that using MSC could encourage them to take more care of themselves in general: The participants agreed that it would be good to use the MSC when they are meeting with visitors: When you go on visits and stuff it's not just childrenbecause I don't like children seeing it anyway, but a lot of other visitors will sit and then they'll just stare and then they'll ask, 'what's she done that for?' and it makes you a bit paranoid so you feel uncomfortable even on your own visits.
One participant thought that use of MSC would help her feel more confident in engaging in work activities: None of the participant expressed any negative reactions to the use of MSC and were keen to have the opportunity to use the products.

Discussion
Ten women participated in a focus group investigating their thoughts and feelings about self-harm scarring and MSC. This is the first study, to our knowledge, that explores the attitudes of women prisoners towards their self-harm scarring, and towards the use of MSC as a strategy to conceal scars. The aims of this paper were to explore participants' feelings towards self-harm scars, examine the effect of scars on life in prison and finally to examine thoughts on the MSC. The results of the focus group have been divided into three themes: (1) Feelings about self-harm scarring (2) Covering self-harm scarring (3) Attitudes towards MSC Participants tended to feel embarrassed about their scars, which often reminded them of bad times in their lives. Feelings of self-consciousness also appeared to be present within the women's discussion about their selfharm scarring and the attitudes of others. Embarrassment and selfconsciousness are well-documented feelings in the self-harm literature (Brown et al., 2009;Castille et al., 2007;Deliberto & Nock, 2008;Gilbert, 2010;Lewis & Mehrabkhani, 2016). Embarrassment has also been confirmed in others with visible skin conditions. In those with vitiligo, skin discolouration of high visibility areas was associated with higher scores on embarrassment and self-consciousness (Ongenae, Dierckxsens, Brochez, van Geel, & Naeyaert, 2005). Much of the embarrassment and shame felt by the women who self-harmed in this study was in line with other findings which suggested that shame is not solely to do with the act of self-harming itself but also specifically to do with the presence and visibility of scars, which MSC has the potential to alleviate (Lewis & Mehrabkhani, 2016).
Participants' feelings about their scars focussed on the attitudes of others. The women were concerned about how they would be perceived by others and worried that people would make negative judgements about them as a result of their scarring. These concerns are consistent with Kenning et al. (2010) who found that prison officers often perceived self-harm as attentionseeking or manipulative. Participants were also concerned that other women might single them out as being abnormal as a result of their scarring. However, participants seemed to suggest that attitudes towards self-harm and self-harm scars in the prison environment could be less negative than in the community, citing self-harm as 'the norm' amongst a female prison population. This idea is in keeping with self-harm as being particularly prevalent amongst women prisoners (Hawton et al., 2014;Ministry of Justice, 2016b).
The women in the study expressed a desire to cover their scars in certain situations when they thought they might be judged by others or may cause distress to others. After the topics of informal support and triggers, concealment of self-harm scarring is the next most discussed topic amongst selfharming individuals (Whitlock, Powers, & Eckenrode, 2006), indicating its importance. When it came to covering up scars, participants broadly described the need to shield their scars from others. This often took the form of selecting particular clothes that concealed their scars (Ongenae et al., 2005), sometimes to the detriment of the individual ('you've got to try to fit your whole outfit round your fricking scars'). Similar to Ongenae et al. (2005), concerns of choosing appropriate clothes to cover scars is one of the most affected quality-of-life measures in people living with scars.
Participants discussed the fact that covering up scars can have the benefit of the individual feeling less conscious or paranoid, suggesting that covering scars may function to make the self feel better. Some women expressed the desire to return to a pre-injured state. One participant described the fact that they would 'love to wake up and for them to just not be there' and another told how she attempted to tattoo over her scars to make them appear invisible. Such restitution narratives (Frank, 1995) are in keeping with findings from Chandler (2014), who found half of her participants provided restitution narratives when describing their self-harm scarring. Such narratives can sometimes be seen as searching for a 'fix' or 'cure', which may not always be possible with self-harm scars (Chandler, 2014). However, MSC could provide a potential way for scars to appear more similar to a pre-injured state.
Several participants described attempts to cover self-harm scarring with regular make-up themselves, but that they found that it was not fit for purpose. Additionally, some participants had used MSC products successfully in the community, as had those in Walker et al. (2014). Use of regular make-up and previous MSC products suggests that covering scarring to achieve a natural-skin look is an aspect of appearance, or self-perception, that is valued by these women and is in line with Chandler's (2014) finding of people who self-harm wanting to return to a pre-injured state.
When discussing MSC, participants' attitudes centred around the fact that the products may lead to them being less conscious of their scars, and application of the products could serve an additional function of encouraging women to care for themselves more generally. Improvements in selfconsciousness has been found when participants were prescribed MSC for skin disfiguration (Ongenae et al., 2005), with an improved quality of life (Holme, Beattie, & Fleming, 2002). If MSC encourages self-care and reduces the visual impact of women's scarring (thus bringing them closer to a preinjured state), it may motivate women to avoid self-harm in the future. Walker et al. (2014) found that women prisoners described using MSC to cover scars as potentially reducing the likelihood of future self-harm, because scars may act as triggers to further self-harm. Also, considering that greater numbers of scars can be associated with higher levels of suicide ideation, MSC may have the potential to reduce suicide ideation by physically covering scars (Burke et al., 2016).

Strengths and limitations
This is the first study to look at experiences of self-harm scars in a prison environment. It is recognised that the effects of self-harm scarring have been underresearched (Chandler, 2014;Hodgson, 2004;Walker et al., 2014) and there is a paucity of literature on this topic (Lewis & Mehrabkhani, 2016).
The authors recognise that the sample for this focus group was limited and took place in only one prison. Because of this, data saturation may not have been reached and the transferability of findings may be limited. This was due to the fact that this was a smaller, exploratory study within a larger study. For this reason, resources and timing did not allow for further data collection, where data may have been triangulated from other sources. Additionally, the participants were self-selecting. This opens up the possibility that the women who volunteered may have certain attitudes towards their scars which are not shared by other women in prison. Participants who are interested in research on MSC are likely to be interested in hiding or covering their scars. Despite this, there are clearly women in prison who would like the opportunity to cover their scars and who believe that this will reduce the impact of their scars on their relationships with others and improve their perception of themselves, opening up the possibility for more effective recovery and rehabilitation.

Implications for practice
There are women in prison who are motivated to cover their self-harm scars because they feel embarrassed or self-conscious and are concerned about the perception of others. These women were positive and enthusiastic about the use of MSC as a way of concealing their scars. This suggests that the use of MSC for women in prison with self-harm scars should be explored further with a view to gathering robust evidence on its effects on women's self-perception, relationships and participation in activities. If MSC is shown to have a positive effect on women's feelings about themselves and their relationships, it may represent a safe, lowcost, acceptable and, therefore, sustainable way to encourage recovery from self-harm and improve the prison environment for the women and those around them.

Future directions
There has been little research on the effects of self-harm scarring on women's self-perception and functioning in the prison environment. These effects will be explored in more detail in the feasibility and acceptability pilot of MSC. Future research should examine the effects of stigmatising behaviour towards self-harm scarring in more depth. Trauma-informed staff training has recently been implemented across the prison estate (Onesmallthing, 2018). This training focuses on ways to respond sensitively to the needs of vulnerable women in prison. Two participants in this study described unhelpful staff attitudes towards self-harm. Since traumainformed training began recently, it may take some time for attitude change to become evident. It is important to be mindful that this focus group took place with a small number of women in one prison; however, future research should explore if staff attitudes have changed and adapted following the training and its implementation. Future research should also examine women prisoners' attitudes towards self-harm scarring more widely across the women's estate, given that the sample included in this paper is small.
The pilot trial of MSC for self-harm scarring is currently taking place; results will be available in the future to determine if it is feasible and acceptable to run a large-scale randomised controlled trial (RCT) of MSC use in the women's estate. It is hoped that this research will lead to a trial which tests the cost-effectiveness of MSC in this environment.

Conclusion
At least some women in prison with self-harm scarring feel embarrassed and self-conscious about their scars and have a desire to cover them effectively. Reactions to the use of MSC were found to be very positive. A pilot feasibility and acceptability study of the use of MSC as a selfharm intervention to help improve women's well-being is currently underway. If MSC is shown to be a feasible and acceptable intervention, a full-scale randomised control trial would be an important next step to provide evidence of cost-effectiveness of this novel approach.

Disclosure statement
There are no conflicts of interest to declare.