Trans in society

It's the duty of health professionals to consider the social dimension of gender identity

Photo by Chang Duong on Unsplash

Sandra Pertot

The three cornerstones of modern transgender theory that underpin gender-affirming health care are that gender is innate and immutable; that social factors cannot influence gender identity; and that if someone says they are trans, they are, and must be affirmed.

Is gender identity innate and immutable?

For some health professionals, there is no doubt. O’Hanlon, Gordon & Mackenzie (2018) confidently claim that “multiple layers of evidence confirm that sexual orientation and gender identity are as biological, innate and immutable as the other traits conferred during that critical time in gestation.”

According to Mandal (2019), “There are several different potential causes of gender differences, these include hormonal changes, exposure to estrogenic drugs and so forth.” However, these results are likely to be compromised by failure to control for homosexuality (Cohn, 2022).

A large-scale study searching for the elusive “trans gene(s)” takes a more nuanced approach. Theisen et al (2019) expanded on the topic of gender identity genomics by identifying rare variants in genes associated with sexually dimorphic brain development and exploring how they could contribute to gender dysphoria. They concluded that:

“The broad spectrum that characterizes human gender identity suggests that, rather than being tied to variation within a single gene, an individual’s gender identity is more likely the result of a complex interplay between multiple genes as well as environmental and societal factors.”

A major effort to find the “gay gene” came to similar conclusions. Ganna et al (2019) performed a genome-wide association study on 493,001 participants from the United States, the United Kingdom and Sweden to explore genes associated with sexual orientation. They concluded that same-sex behaviour is influenced not by one or a few genes but by many. They stated:

“Nevertheless, many uncertainties remain to be explored, including how sociocultural influences on sexual preference might interact with genetic influences.”

What role might nurture play?

Trans activists seem to be offended by the idea that some people may come to believe they are trans as a result of social influence of one kind or another (Riggs, 2019). Dr. Damien Riggs, who is not a registered health professional but identifies as a psychotherapist who specialises in working with young gender-questioning people, was quoted by the Australian Psychological Society as saying:

“Empirical evidence consistently refutes claims that a child’s or adolescent’s gender can be ‘directed’ by peer group pressure or media influence, as a form of ‘social contagion’.

“To say that there is a trans-identity crisis among young Australians because of social media pressure is not only alarmist, scientifically incorrect and confusing, but is potentially harmful to a young person’s mental health and wellbeing. 

“Claims that young people are transgender due to ‘social contagion’ serve to belittle young people by asking them to believe that their sense of self and their gender is nothing more than a by-product of what other people might think or say through the media.”

Statements such as these reveal a poor understanding of the complexity of social factors.

Social influence is integral to all human societies: it describes how our thoughts, feelings, and behaviours respond to our social world, including our tendencies to conform to others, follow social rules, and obey authority figures (Heinzen & Goodfriend, 2018). Every person, one way or another, is affected by sources of influence, including advertisements, political campaigns, discussions with friends, documentaries and so on.

Social contagion is one form of social influence, which Riggio & Riggio (2022) define “as the seemingly spontaneous process by which information, such as attitudes, emotions, or behaviours, are spread throughout a group from one member to others”. They explore the implications for mental health, noting that it has been recognised for some time that problems such as anxiety, eating disorders, violence and deliberate self-harm can be increased in social groups, likely due to imitation of others’ behaviour. Even more concerning for these authors is the seeming contagion of suicides, with some individuals, particularly young people, attempting suicide following a high-profile person’s suicide.

In recent times considerable attention has been paid to the impact of social media on the mental health of young people. The American Academy of Child and Adolescent Psychiatry (2018) reported on the role that social media plays in teen culture today. The report quoted surveys which showed that 90 per cent of teens ages 13-17 had used social media. Seventy five per cent reported having at least one active social media profile, and 51 per cent reported visiting a social media site at least daily. Two thirds of teens had their own mobile devices with internet capabilities. On average, teens were online almost nine hours a day, not including time for homework. The use of social media has increased since this study.

Martinez, Jimenez & Gerber (2023) comment that, given their developmental stage, adolescents are a population prone to social contagion not only because they may be especially susceptible to the influence of social media, but also to that of their peers.

Haltigan, Pringsheim & Rajkumar (2023) describe the well-documented increase in popular content-creators with self-diagnosed mental health symptomatology on social media platforms such as TikTok, Tumblr and Instagram. The range of the conditions portrayed includes attention-deficit/hyperactivity disorder; dissociative identity disorder; functional tic-like behaviours; multiple-personality disorder; non-suicidal self-injury;  obsessive-compulsive disorder; and Tourette’s syndrome.

As a result, there has been an increasing presentation to health professionals of young people expressing symptoms of these disorders. For example, Hull and Parnes (2021) describe the cases of six teenage girls, each with the sudden onset of tic-like movements. They found that the symptoms and history reported were quite different to those typical of Tourette’s syndrome, leading to the diagnosis of functional tics—that is, driven by psychological factors. All patients reported exposure to a specific social media personality before symptom onset. The authors concluded that social media may contribute to the spread of functional neurologic symptom disorder, which was previously thought to occur only following physical proximity to a person with the syndrome.

Similarly, Frey, Black and Malaty (2022) report that increased social media consumption during the COVID pandemic and the many misleading videos of tic-like behaviours were driving the rapid increase in these functional tic presentations. They also found that the quality of these tics mirrored many of the tics seen on popular social media channels.

Rettew (2022), a child psychiatrist, reported an influx to his and other clinics of adolescents presenting with self-diagnosed Dissociative Identity Disorder (DID); each was claiming that a number of different personalities emerged at different times. Much of this seems to be driven by a small number of influential people on TikTok who have posted very popular videos in which they describe their DID in great detail. Rettew theorised that in cases where the DID symptoms were not part of that person’s life before watching TikTok, they may result from anxiety or point to an underlying genuine identity disturbance; both options need to be considered during assessment.

If young people are adopting these conditions as part of their identity, do they recognise this or genuinely believe they have the condition? As Rettew points out, either way the young person must be treated carefully and respectfully.

Over the last decade, mental health problems in general have been increasing in young people. The Australian data obtained by Wilkins et al (2022) reflects worldwide trends of a sharp decline in mental health for the 15-24 and 25-34 age groups. Although the trend is evident from 2011 for these two age groups, mental health deteriorated substantially between 2019 and 2020.

If someone identifies as trans, must that be accepted unconditionally?

As the mental health of young people has been declining, the rate of those identifying as trans has been increasing, and it is recognised that these trans-identifying young people typically have significant co-morbid psychological distress. Young people in such a vulnerable group are more likely to be influenced by social media than a more confident, self-assured person, although even those people are at some risk.

So, the research demonstrates that social media representations of health conditions can lead to young people mimicking those disorders, not only in mental health but with neurological conditions as well.

On what grounds do gender-affirming health professionals consider that gender identity is beyond such influence? There are literally hundreds of videos across multiple platforms featuring many different aspects of gender identity and its many options for acceptance and affirmation.

Video: Some glimpses of the online landscape explored by young people every day

Transition as a solution

On the evidence, it is likely that some of today’s young gender-questioning people come to believe that being trans is the explanation for their ongoing distress, and that transitioning will resolve it.

Gender-affirming health professionals reject this possibility. Their view is that unlike the other conditions being investigated, gender identity is not a mental health problem, but is like sexual orientation. Would I challenge a young person who said they were gay?

The answer is, I would and I have. Dr. Brendan Zietsch, the “gay gene” researcher, has summarised the view that I share:

“… people tend to want black-and-white answers about complex issues. Accordingly, people may react to our findings by saying either: ‘No gay gene? I guess it’s not genetic after all!’ or ‘Many genes? I suppose sexual preference is genetically fixed!’ Both of these interpretations are wrong.

Sexual preference is influenced by genes but not determined by them. Even genetically identical twins often have completely different sexual preferences. We have little idea, though, what the non-genetic influences are, and our [research] results say nothing about this.

Dr Zietsch’s comments highlight an important issue relevant to the complexities of same-sex attraction and gender identity: the differences between characteristics and behaviours that are innate, acquired or situational.

One of the advantages of having been a clinical psychologist over several decades is that I got to observe and be part of change in knowledge and practice over time. In the early 1970s, when I was doing my postgraduate clinical training, gay rights were still a contentious issue. Indeed, at that time Sydney psychiatrist Dr. Neil McConaghy was conducting aversion therapy using electric shocks on young gay men. Some chose to undergo treatment to avoid imprisonment, others in reaction to the personal and social pressure that openly vilified gay people back then (Smith, Bartlett & King, 2004). Smith et al report that while many participants were able to psychologically survive this treatment and found happiness in same-sex relationships, most were left feeling emotionally distressed to some degree.

Fortunately the clinical course I did rejected Dr. McConaghy’s approach, and we explored other theories and clinical practice to support sexuality-questioning clients.

Innate?

As attitudes changed over the following years, clinicians like me began to see men who had always known they were gay and had married in order to ignore their sexuality or use marriage as a shield for secret liaisons.

There was a time lag before women began to present with confusion about their sexuality. These married women had never considered they were at all attracted to women until they met the woman who changed their lives. The awakening for some was quite sudden, for others it was a slow growing awareness of attraction to this one particular woman. Among the mature women, many had experienced good relationships with males, and only later started relationships with females.

Then there were adolescent males who thought they were gay. Some were attracted to males and wished they weren’t, and they needed gentle support to work their way through this confusion to find what they were able to accept. This typically involved seeing the parents. One mum pleaded with me that surely he was just “a little bit” gay and would grow out of it.

Some young males worried they were gay because they were being bullied by peers using homophobic slurs. Others began an obsessive cycle of looking at other boys’ penises at the urinal, then panicking about why they did that, leading to the need to check whether they did feel aroused whenever at the urinal. Still others found some male movie stars attractive, so what did this mean?

I did not take an “affirming” approach with any of these clients—how could I possibly know what was the right path for someone I had only recently met? Each was supported to find their own answers to their questioning. For some, that meant learning to be comfortable being gay. For others, it meant coming to understand that they were not same sex-attracted, and learning why they had come to think they were. And then there were those coming to understand that it was possible to be attracted to people of either sex.

The common factor in my approach to all sexuality-questioning people was to let them know they didn’t have to make a firm decision immediately, that this might be an unfolding story for them which might change over time: my aim was to give them the confidence to know and accept themselves, wherever that might lead.

Acquired

Then there were the feminists in the emerging women’s liberation movement. For some of the more radical members, the concept of “political lesbianism” (Palmer, 2022) became popular during the second wave of feminism across the 1960s-70s. This refers to the idea that women can choose their sexual orientation, and that a true feminist might reject heterosexuality in order to fully embrace a female-centric life and avoid the troubles of patriarchy on an intimate level.

Feminist writer Julie Bindel (2014) has lived the concept of choosing to be a lesbian: “I think the opposite of having an innate, biological explanation—there’s no evidence for that—has to be some kind of choice, as well as some deep-rooted, embedded responses that developed through different experiences in our childhood.”

Situational

In what is termed “situational homosexuality”, some inmates in single-sex prisons will engage in consensual same-sex relationships but return to heterosexual sex after release.

Conclusion

Dr. Erica Anderson, a clinical psychologist with 30 years of experience working with gender-questioning clients and a former board member of the World Professional Association for Transgender Health, has acknowledged that social factors can influence some young people to believe they are trans. She sums up the current dilemma for gender-affirming health professionals:

“The biggest question today is not whether gender-affirming care is appropriate for transgender youth. The question is: Who is transgender and at what point should medicines be used?”

The evidence that gender is not innate and immutable is extensive. In my view, any health professional—especially any psychologist for whom social psychology is a core undergraduate unit—who deliberately excludes the possibility of social factors influencing some people to claim they are trans is failing in their duty of care.

Dr. Sandra Pertot recently retired after 50 years of clinical practice specialising in human sexuality, including sexual dysfunction, sexual orientation and gender diversity