Last week saw another attempt to silence debate and research whose findings diverge from an accepted orthodoxy. In the Advocate, transgender activist Brynn Tannehill decried a 2017 abstract that appeared in the Journal of Adolescent Health, stating that the research into rapid onset gender dysphoria or ROGD was “biased junk science.” The research that Tannehill so strongly objected to was undertaken by Lisa Littman, MD, MPH. Littman surveyed parents about their teen and young adult children who became gender dysphoric and transgender-identified in the context of belonging to a peer group where one, multiple, or even all the friends in a pre-existing peer group became transgender-identified in a similar time frame, an increase in social media use, or both. The findings of the research support the plausibility of social influences contributing to the development of gender dysphoria. The full research paper has not yet been published.

Tannehill subsequently posted the article to the Facebook page of the World Professional Association for Transgender Health (WPATH). A discussion ensued in which some commentators asked WPATH leadership to request that the journal retract the abstract. “So is something being done?” wrote one commentator. “As in are [sic] the Journal being asked to make a statement to retract or apologize for including it?” Psychiatrist and WPATH board member Dan Karasic, MD responded simply. “Yes.” (These comments were deleted from the original thread, but screen caps and a fuller description of what took place can be found here.)

As a therapist, I have spoken with hundreds of parents of teens who have announced a trans identity “out of the blue,” and I can corroborate Littman’s initial findings. The majority of these parents have a daughter aged 14 or 15 – an age at which teens are particularly susceptible to peer influence. These teens often have one or more of the following factors that contribute to their social struggles: they are academically gifted; they are on the autism spectrum; they are same-sex attracted; they have experienced trauma or major disruption; they have other mental health diagnoses such as anxiety or depression; they have a learning disability. Parents often report that their child made a sudden announcement about being transgender after spending increased time on social media sites focused on trans issues, and/or having one or more peers come out as trans. Some teens have even admitted to their parents that they have come out as trans “to fit in.”

In addition to the belief that they are trans, these teens also appear to have acquired rapidly the steadfast conviction that social and medical transition (now euphemistically labelled “gender confirmation”) must be undertaken immediately. Parents report to me that a teen’s coming out announcement is often accompanied by an immediate request for hormone treatments. Discussions of surgery usually soon follow. Some teens have even identified the local gender clinic nearest them where they can receive hormones, and share this information with parents at the time of their announcement. Parents are sometimes told that if they don’t accede to these requests for medical intervention, their child will become suicidal.

The belief that medical transition must be pursued urgently has almost certainly been suggested to them on the internet, by the mainstream media, and perhaps also by peers. This is despite the fact that most transgender adults transition later in life and survived adolescence without transition. Furthermore, the empirical claim that early transitions work is based on a small subset of studies whose results may not apply to adolescent onset cases, or cases where there are other psychiatric issues. In addition,the widely cited suicide rate that is often mentioned as a justification for urgent intervention is based on a study which does not prove that there is a causal link between gender transitioning and improvement in mental health. It is still unknown whether transition changes suicide rates for gender dysphoric individuals. No study to date has looked at whether parental support for teen gender nonconformity without medical transition results in a reduction of distress, though anecdotal evidence appears to indicate that it may. While there is evidence that medical intervention benefits adults with gender dysphoria, there currently remains a lack of evidence indicating that medical intervention is the best and only first-line treatment for children and teens suffering from the condition. Meanwhile, the push for immediate intervention is becoming entrenched as an orthodoxy in mainstream media accounts and within professional organizations – possibly steering us down a path that could potentially result in the unnecessary sterilization of of teenagers in the U.S. and around the world.

Activists and certain clinicians who are sympathetic to the activist movement appear to feel threatened by the idea of rapid onset gender dysphoria because the suggestion that dysphoria might be influenced by social or cultural factors undermines the notions of innateness. If dysphoria isn’t innate, justifying medical intervention becomes more complicated.

In fact, it must be true that there are cultural and social factors at work in gender dysphoria. If a social act such as donning a certain article of clothing or being called by a different name can alleviate a child’s distress, then how can the problem that caused that distress possibly be entirely biological? The diagnosis of gender dysphoria in children is based largely on culturally bound behaviors. For example, the official diagnostic description lists criteria such as a child having “a strong preference for the toys, games, or activities stereotypically used or engaged in by the other gender.” There is no lab test for it, no physical manifestation. Those who undergo medical intervention for gender dysphoria are usually physically healthy and phenotypically normal.

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In 1851, a US physician published a paper in scholarly New Orleans Medical and Surgical Journal in which he described a new disorder. “In noticing a disease that, therefore, is hitherto classed among the long list of maladies that man is subject to, it was necessary to have a new term to express it,” wrote Cartwright, and named the new syndrome drapetomania. Drapetomania was a disease of slaves that caused them to run away. Early symptoms included slaves becoming “sulky and dissatisfied without cause.” Treatment to stop further development of the disease at this point called for “whipping the devil out of them” as a “preventative measure.” The eminent psychiatrist and psychoanalyst Thomas Szasz likened Cartwright’s analysis of the “disease” that would make a slave want to run away with our modern tendency to diagnose and medicate depression in those who work long days doing menial tasks in a windowless cubicle.

This is not to say that there is no such thing as major depressive disorder, or to insinuate that medication is an ineffective or inappropriate response to feelings of discontent or lack or meaning. It is to point out that our distress occurs in a social and cultural context, and is in part interpreted and even constructed by this. In what philosopher Ian Hacking described as the “looping effect,” what our doctors expect us to manifest is offered to us as the symptom language through which our distress finds expression. And when we express it thus, the psychiatric establishment becomes further convinced that they are dealing with a discrete entity, that the illness is, indeed, a natural kind, occurring outside of human-made categories. In fact, mental health symptoms always have some kind of social or cultural input, as is illustrated by a cross-cultural look at psychiatry.

The various hobgoblins of the psyche that we call disorders each have roots in the body and its biology. Genetic factors have been found to play a role in virtually all of the diagnoses in the Diagnostic and Statistical Manual of Mental Disorders, or DSM. Yet they are not merely products of our biology. Their particular manifestation is dependent upon our individual biography, the zeitgeist of our current cultural milieu, and the particular time and place in which we find ourselves. The culture provides the symptom language, the metaphorical wrappings in which our distress is clothed.

The annual number of referrals to the gender dysphoria specialist team at the Astrid Lindgren Children's Hospital in Stockholm. Article in Swedish: https://t.co/ZbFg753w6o pic.twitter.com/IEa8qvIk7s

— Amir Sariaslan (@AmirSariaslan) January 14, 2018

One mental disorder demonstrably caused largely by biological factors is schizophrenia. Something like schizophrenia exists around the world, it appears to be quite heritable, and there is evidence that exposure to certain viruses in the womb may predispose someone to developing the disease later in life. However, schizophrenia manifests in markedly different ways in different cultures. Strikingly, the social context in which the disease occurs appears to have a significant effect on prognosis. While a diagnosis of schizophrenia in Western cultures usually comes with an expectation that the person will be burdened with a debilitating illness for life, schizophrenics in other cultures are more likely to experience a full remission. Even a disease, then, that is significantly biological in origin has an important component that is socially constructed, and the social component can have a substantial effect on whether those suffering from the disease do well or do poorly.

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To point out that a diagnosis has a socially constructed component is not to assert that it isn’t real, that its sufferers are “crazy,” or that they don’t deserve compassion and treatment. Acknowledging the reality of the social construction of psychiatric diagnosis does, however, allow us a wider range of options to choose from when deciding how to address the attendant suffering.

In therapy, we pay attention to cognitions because our thoughts influence how we respond to things. Cognitive therapists often point out that there is the thing that happens, and then the story we tell ourselves about that thing. A psychiatric diagnosis can be a story we tell ourselves about the feelings we have. The diagnostic criteria for childhood gender dysphoria in the current DSM includes such items such as the following:

In boys (assigned gender), a strong rejection of typically masculine toys, games, and activities and a strong avoidance of rough-and-tumble play; or in girls (assigned gender), a strong rejection of typically feminine toys, games, and activities.

According to the DSM, then, not liking girly things as a child could mean that I have gender dysphoria. But for any individual, alternative explanations should be ruled out before life-altering interventions are prescribed. For example, researchers have noted that cross-gender play and clothing preferences in childhood are associated with adult same sex sexual orientation. Symptoms that some see as evidence of being transgender can also be an early expression of being lesbian or gay. Given that research indicates that the majority of cross-sex identified kids will desist if left alone, and that most of these will grow up to be gay, lesbian, or bisexual, it seems prudent in many cases to wait and see.

Consider another explanation that has been less widely discussed or even acknowledged: since the majority of teens presenting at gender clinics are natal females, we might also consider that many girls feel uncomfortable with gender roles, and that discomfort with one’s body is an experience shared by 90% of adolescent females. Teen girls are often very preoccupied with fitting in socially, and are generally more likely than teen boys to manifest emotional problems. Could teen girls be latching on to the narrative supplied online and in the media to construct a story about themselves that serves to explain their feelings of difference while offering a path to transformation?

Australian psychiatrist and psychoanalyst Roberto D’Angelo works with gender dysphoric young people in his practice. He has noted the tendency of young people to adopt the symptom language of gender dysphoria as a way to explain distress that may not have other words—

Dysphoria is often presented as a “condition” by patients I see, which they are unable to describe very clearly. They frequently have no sense that this feeling might have developed in response to social or interpersonal contextual factors, including family dysfunction and trauma. I think that with some ROGD, the individual is already struggling and unhappy (dysphoric) due to other issues and trans is appropriated as a solution to their difficulties. People I have seen often have a fantasy that transitioning would make them into a “new person,” free of all the old difficulties. I think the social contagion aspect may relate to the availability of the trans narrative as a compelling solution to pain and distress.

It matters which story or explanation we choose – how we decide to construct our distress – because this will in large part determine the kinds of responses open to us. Some clinicians are constructing feelings of gender discomfort in teens as indicative of the need for medical intervention that includes sterilizing hormones and amputation of breasts. Given the drastic and permanent nature of these interventions and the relative paucity of data on long-term outcomes for those who transition as children and young people, does it not make sense to explore other possible stories that might suggest different treatment pathways?

A commitment to dialogue, inquiry, and rigorous research has helped us to debunk politicized diagnoses such as drapetomania. It has helped broaden our understanding of schizophrenia so that we understand its cultural components, including the ways that the diagnosis has been misused as social control. And it has helped us to discover less invasive and more humane ways of treating this condition. Littman’s initial research does indeed seem to confirm that there are significant social and cultural elements involved in the current tendency among teens and young people to declare themselves as trans. Research likes hers can help us learn more about who might best benefit from which treatments. And isn’t that what we all want?