Society’s Perfect Storm: Mental Health, Body Image, and Social Media

From 1995 to 2016, a period spanning over two decades and thousands of patient encounters, I did not meet a single transgender-identified young person. Today, I may encounter several transgender-identifying adolescents in a single afternoon clinic. My experience aligns with epidemiological trends, which show an exponential rise in transgender identification.

This surge in gender-related distress among young people runs parallel to an unprecedented integration of technology into daily life, fundamentally altering how information is consumed and how young people socialize and learn. Chaukos-Bradley and colleagues (2022) describe this as a “perfect storm” fueled by the mutual uptake of smartphones and social media. The “phone-based childhood” disrupts development by focusing young people on social comparison and appearance, and amplifying sociocultural pressures.

Narcissus Stares into a Smartphone

Through most of human history, appearance preoccupation would be impossible as a still pool of water was required for a brief glimpse at our reflections. From ancient obsidian mirrors to the invention of glass mirrors in 1835, technological advancements slowly allowed humans more opportunities to view themselves. In stark contrast, widespread adoption of both smartphones and social media provided two simultaneous and profound technological advances. All at once young people had easy access to a flood of self-referential images, online pornography and a previously impossible degrees of social comparison. Particularly among girls, pressures to be “camera-ready”, combined with algorithms, filters, and amplification effects sculpted widespread body dissatisfaction and increased depression and anxiety. Just at this time was the large increase in transgender self-identification and associated transgender–related ideologies including:

• Infiltration of Dysfunctional Ideologies: Post-modern and anti-scientific ideologies seeped from academia into society, promoting narratives such as oppressor-victim binaries, disregard for traditional labels and boundaries, and an excessive focus on personal identity.
• Indoctrination Techniques in Schools: Techniques like brightly colored “gender unicorns” and requests for “preferred pronouns” exposed children to campaigns to displace traditional understandings of sex and sex roles. Schools normalized concepts like “gender identity” (the idea of a gendered soul) and the belief that humans can change sex (e.g., “trans women are women”) or could be born in the wrong body.
• Lack of Nuanced Discussion on Sex and Sex Differences: There has been significant resistance from both political left and right to openly acknowledge humans are a sexually dimorphic species. Acknowledging this reality could have helped to undermine dysfunctional theories about human sexuality and identities. Instead, transgender ideology has conjured up theories regarding oppressive regimes of “cisnormativity” and demanded that society ignore humans’ evolved sex differences and the sex binary.

The Medical Perfect Storm: The Placebo Effect and “Affirmative Care”

Unfortunately, at a time when the medical and mental health establishments should have been a bulwark against developmentally inappropriate and unscientific theories sweeping through society, they were experiencing their own “perfect storm.” As detailed by Clayton (2022), the second perfect storm was the development of a widespread belief that medical treatments (puberty blockers, hormones, and surgery) were the optimal solution to youth gender-related distress.

This belief in gender-affirming treatment was bolstered by

• A poorly considered loosening of diagnostic labels in 2013.
• A reasonable desire to help gender non-conforming young people.
• Clinicians’ desires to be seen as compassionate advocates.

However, the gender-affirming care movement would not have swept through medicine were it not for clinicians confusing placebo effects with genuine treatment effects. Placebo effects encompass a range of non-specific factors, primarily patient expectations and clinical relationships. The surge of enthusiasm from Gender Affirming Care (GAC) providers and within the broader culture maximized these placebo effects, especially given the framework that patients “know” their gender identity and require “life-saving” and “evidence-based” surgical and hormonal treatment.

While a small number of adults throughout history have had a persistent desire to be the opposite sex, gender dysphoria was formerly a rare medical and societal curiosity. Despite a lack of robust evidence, a narrative was promoted that hormones and surgical treatments were evidence-based, ethical, and lifesaving. This viewpoint is contested in adults, but until two decades ago, doctors had been sensible enough to avoid calling children transsexual. The name change from transsexual to transgender was in part to make it easier to apply this label to gender non-conforming children.

Highly flawed observational retrospective “research” from the Netherlands portrayed a regimen of puberty blockers, hormones and surgeries as experimental, but effective treatments. In the 2000s and 2010s, enthusiastic clinicians spread this approach worldwide. This “runaway diffusion” in pediatric gender medicine was aided by a social justice movement stigmatizing other approach and adopting civil rights language. Traditional media, social media companies, left-leaning political organizations, government bureaucracies, universities, and medical societies all tossed aside skepticism to appear virtuous and supportive. Transgender advocates were allowed to craft institutional policies, giving gender affirming ideologies authoritarian control over important bureaucracies and institutions.

Clayton (and others) have noted that this affirmative model of treatment was promoted throughout medicine in an unusual manner, characterized by:

• Excessively Negative Portrayal of Alternatives: Previous standard treatments and current alternative options were demeaned, such as labeling watchful waiting as outdated and stigmatizing psychotherapy as “conversion therapy.”
• Exaggerated Suicide Narrative: An exaggerated suicide narrative was used to pressure parents, other clinicians, and communities to accept opposite-sex identification. Reasonable parents would only agree to such drastic treatments for a socio-culturally created problem if they were bullied by claims that hormones and surgeries reduce a very high suicide risk.
• Framing as Civil Rights: Hormonal and surgical treatment was framed as civil rights, elevating “gender-affirming” providers as ethical and heroic.
• Stigmatizing Other Approaches: Those who preferred other clinical approaches were stigmatized as “anti-trans,” and gender-affirming treatments were presented as the only option at gender clinics.
• Concerted Promotion Efforts: Organized and concerted efforts were made to have medical societies, universities, government bureaucracies, clinicians, and activists promote gender-affirming treatments.
• Biased Research: Clinicians already employed in gender-affirming care conducted observational research to confirm their pre-existing belief that this care is ethical and effective. This is precisely the short-term, uncontrolled, and patient self-report-based research most likely to capture placebo effects. The results of these low-quality studies were then used to justify continuing and expanding gender-affirming treatments.
• Hostility Toward Those Who Raise Concerns: A long list of clinicians, researchers, and even gender-care specialists have been attacked for expressing caution. These attacks have been fueled by social media-inspired and online campaigns, which transformed academia into a space replete with ideology, ad hominem attacks, moralization, and witch-hunts.

Only over time did the more skeptical medical and mental health community call for systematic evidence reviews. These reviews have repeatedly indicated that little is certain about outcomes, and even the short-term effects of gender-affirming care are underwhelming. When positive effects are observed, they are small enough that placebo effects would reasonably explain the minor gains.

Medical professionals are expected to be mindful of placebo effects, conflicts of interest in research, and the potential harms of overtreatment. Yet Western medicine, especially in the United States, has a propensity for naive interventionalism. We have a medical system biased toward action rather than reflection, particularly when the “treatment” creates new profit centers.

For dissatisfied young people, adopting an “illness identity” can provide a sense of self and belonging in a fragmented and rapidly changing world. Yet adopting an illness-based identity carries the risk of defining oneself through a diagnosis. In the case of youth gender medicine, it carries the additional harms of destroying healthy body parts and adopting a fundamentally false belief about oneself.

As Clayton noted, “A medical profession that does little to distinguish placebo effects from specific treatment effects risks becoming little different from pseudoscience and the quackery that dominated medicine of past times, with likely resulting decline in public trust and deterioration in patient outcomes.”

Kris Kaliebe is a psychiatrist and educator who explores how social media and cultural pressures are impacting young people’s mental health.

Watch Dr Kalibe’s talk at the Lisbon Bigger Picture Conference here.

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Photo by camilo jimenez on Unsplash