Self-harm is about communication. It is like a scream without sound: painful, distraught, frightening and perplexing. It can be confusing and terrifying for those who witness it and for those who do it. In this paper, I shall attempt to explore some thoughts about how we can begin to understand acts of self-injury and their implications for clinical work. My hypothesis is that self-injury is a symptom. This symptom may take the place of words, and functions as a means of communication. In particular, I will be suggesting that self-injury is a specific consequence of childhood abuse. Recent statistics from research at ‘Hackney Off Centre’ indicate that for those young people that self-injure, 75 per cent have been sexually abused in childhood. (These statistics bear close resemblance to Bristol Crisis Service for Women and 42nd Street 1995 among others.)