I’ve long been fascinated by the phenomenon we call social contagion, or the spread of behaviors, emotions, attitudes, and beliefs through a population via social interaction. Various writers introduced the term in the late nineteenth century, and I first came across it in the mid-1990s. While doing research for a book I was writing on the explosive growth of attention-deficit/hyperactivity disorder (ADHD) and the use of Ritalin, I discovered Elaine Showalter’s Hystories, a catalogue of social and medical epidemics fueled solely or in part via social contagion.
Social contagion implies that a disorder, disease, or dysfunction has spread via social contact. Using this definition, a dance craze, a political party, or even a religion could be considered by some to be the result of social contagion. The term also carries a negative connotation: If the condition is generated by social interaction, the thinking goes, the problem isn’t real or serious. It allows any physical/emotional problem to be challenged, since all conditions are influenced by their social environments.
Psychiatric Social Contagions in America Since 1980
In the 1980s as a frontline behavioral/developmental pediatrician, I encountered a very real epidemic,the eating disorder anorexia nervosa in teenage girls (untreated anorexia can lead to death). Once parents became aware of behavior patterns related to this disorder, they were much more vigilant and aggressive in addressing their daughters’ eating habits, particularly at a younger age. Treating this condition when a child is eleven or twelve is much easier than waiting until that child is fifteen or sixteen. Following a surge of patients, it faded away. Anorexia nervosa still presents today, but not at the rates seen in the early 1980s.
Over the years, I’ve witnessed other psychiatric trends that similarly expanded and then declined, sometimes abruptly. In the mid-1980s, child sexual-abuse concerns exploded, culminating in the McMartin arrests and trial of several child-care providers (no one was ever convicted) based upon children’s statements of physical and sexual abuse. At the time, I was told by the director of my local psychiatric hospital that I should consider all girls I treated to be likely victims of sexual abuse. I found this puzzling; I wasn’t hearing that from the children I saw and was reluctant to press them on the subject. I was concerned that asking more than once or twice would pressure them to give me a positive answer and potentially result in false memories. It turns out I was right.
In the early 1990s, the false memory phenomenon was an important factor in another psychiatric epidemic: Multiple Personality Disorder ([MPD], in which women in treatment (women constituted the vast majority of MPD patients) recalled repressed memories of physical and sexual abuse that resulted in significant psychiatric impairment. The work of many, especially Elizabeth Loftus, demonstrated the inconsistencies of memory and was instrumental in the 1994 Ramona court case.
In this lawsuit, a father successfully sued his daughter’s psychiatrist and therapist for malpractice after his daughter, who was being treated for an eating disorder, sued her father, claiming that he had sexually abused her. The frequency of MPD diagnoses dropped abruptly after the verdict and has never returned to levels seen in the early 1990s.
Gender dysphoria, the most recent psychiatric diagnosis to explode, has similarly resulted in a surge in the number of people, especially teenagers, seeking treatment to change their natal gender. Observations from the front lines (my practice in Walnut Creek, an affluent suburb of San Francisco) and other indicators suggest that peak interest in transgender thinking and feeling may have been reached and is now in decline—and not just because our current federal administration has declared war on them.
The Sudden Rise of Gender Dysphoria
I had been in practice for almost thirty-five years before encountering my first patient with a gender question. Because my clinical orientation is strongly influenced by family and social systems like schools, neighborhoods, and a variety of ethnic values, I’ve long had an interest in the roles environment and society play in behavior. About ten years ago, I met a ten-year-old natal boy, Nace (his name is changed to protect identity), who was acting out at home and at school, including being especially verbally provocative towards his parents. About four years later, Nace announced he was gay; then, around 2021, he told his family he wanted to transition to female.
His was the first family I knew to utilize the University of California, San Francsico (UCSF) Child and Adolescent Gender Center, one of the country’s few specialty clinics at that time. While I was no longer directly involved with Nace’s care at that point, I stayed in touch with family members. They told me that at sixteen, Nace wanted to be known by female pronouns and was receiving hormonal treatments at UCSF. (Nace now attends college as a woman.)
Around the same time, Robyn, a sixteen-year-old natal girl I had known since she was six, told her parents she wanted to be called Rohan and to transition to male. The young woman, an adoptee, never quite lived up to her family’s expectations, and her parents were quite resistant to her demands. After several unsuccessful suicide attempts (pill overdosages) and hospitalizations, she was transferred to a residential therapeutic community. About two years ago, I checked in with Rohan’s mother. At twenty-one, Rohan selected “female” on her driver’s license application and had been in an eight-month relationship with a man.
By spring 2023, I was meeting with three families with teens who wanted to transition to the alternative gender. Something was in the air—after not seeing a single transgender dysphoric child/family in nearly forty years, I was now seeing three. It reminded me of my 1980s wave of anorexia nervosa cases.
Feeling that I needed more information on teen transgender treatment, I called a colleague at the UCSF specialty clinic for guidance. The advice I received felt a lot like box-checking; given the multiple processes I was seeing in the patients and their families, it also felt reductive. Could all their unhappiness (and diagnoses) be traced to being in the wrong body, or had their previous unhappiness led them to believe changing their gender would be the solution to their problems?
Where Have All the Goth Kids Gone?
In passing, I wondered where all my Goth patients had gone. For about fifteen years, I could count on meeting a teen dressed in black, with purple or black hair and wearing so much metal that I could hear them clanking down the hall long before they reached my office door. In making these choices, they were following a tradition of alienation that has accompanied teenagers since the term began to be used sometime in the early twentieth century. Only when public high schools became commonplace were young people in their teens able to congregate without their parents or minister in attendance. First there were flappers, then rebels without causes, then hippies.
I do not mean to trivialize any of these phases. But for more than a century, teens have used behavior, language, and dress to say, “I feel different and I’m not going to hide it. I’m really going to show you how different I feel.” Social contagion was clearly part of this process. So, when I wondered what happened to all the Goths, I surmised that the unhappy teenagers of the 2010s had found a different home and identity on the more-welcoming websites and social media circles of the transgender world.
One can only speculate how each generation “chooses” its particular expression of alienation. Resistance to conformity and standards is a constant, but why hippies in one generation and Goths in another? While I try to avoid speculation, it seemed to me that the teen transgender phenomenon was telling us something about this generation’s discomfort with traditional sexual/gender roles.
Getting Silenced
To become further educated about this new type of alienated teen, I attended a national meeting of the American Academy of Child and Adolescent Psychiatry in 2019. Here, I met a child psychiatrist who was running a clinic for transgender children and teens in midwestern city. Transgender was a hot topic that year, and there were many presenters. But he was the only expert who didn’t seem to me to have a proselytizing agenda. As a point of information, many of the presenters were transgender themselves, and this particular psychiatrist was gay; I mention this because orientation can be relevant (I’m a straight, white, Jewish male boomer). In supporting teens who sought identity by changing genders, professionals—many of whom had themselves experienced prejudice and discrimination—may have been driven by a misplaced advocacy for the civil rights and social justice they had been denied.
What made this expert unusual was his openness to my questions. On one occasion, we spent more than an hour talking after the conference. He told me my concerns and questions about the transgender phenomenon I was seeing were quite reasonable. He agreed that elements of social interaction (especially online) were involved, leading to a large increase in teenagers seeking treatment. He also warned me not to go public with my feelings or concerns, especially since I practiced in the San Francisco Bay area where cancel culture ruled. “Your office will be fire-bombed,” he said. While he was mostly joking, he was also serious about the consequences of questions being asked in this notoriously liberal area. My wife and grown sons agreed with him, so I limited my worries to my practice.
Negotiation not Affirmation
As I worked with families, it occurred to me that I had never before seen situations in which teens were given so much power over their parents. Uncertain or resistant parents had been told by other experts or the media that affirmation of their child’s feelings (by supporting gender change) was critical to their mental health. To do otherwise was to increase the risk of depression and suicide.
But it made me quite uneasy. All the kids I saw had long histories of problems in school, with friends, and with their families. Maybe it was all about being in the wrong body. But none of them had said anything about gender until they reached puberty or middle school (at the earliest). I was uncomfortable with the idea that a thirteen- or fourteen-year-old could offer “informed consent” to changes that might have permanent effects (“I’m never going to have children,” or “I can adopt.”).
So, in my office, it was negotiation (something I always encouraged in families with teenagers), not affirmation. It wasn’t always easy, but for the majority of kids I was seeing, the drive for gender change diminished as they got older and gained more life experience. This pattern reminded me of so many of the teens I treated who went through strong rebellious phases only to have their behavior and decisions evolve and mature when they were in their late teens and early twenties.
A Change in the Air
A change in the balance on teen transgender began before Trump 2.0 took over. News from Scandinavian countries shifting their standards and treatment for gender dysphoria began arriving in my area in 2021. The United Kingdom’s Cass Review issued an interim report in 2022; in its final report (April 2024), the author contended that evidence for the long-term benefits of early interventions (hormone blockers, hormones for transition, and surgeries) was not clear enough to justify their continued use. The report recommended a more cautious approach, especially one emphasizing broader evaluations and psychotherapeutic treatment.
A June 2022 cover story in the New York Times Magazine also broke new ground. Finally, a mainstream media outlet raised the same questions I had asked three years earlier. While the article generated great criticism from the LGBQT+ community, the questions were at least being openly asked.
The Cass Review and others noted a critical difference between the cohort of children and teens who were studied and followed in the single long-term project on transgender treatment performed by the Dutch, known as the Dutch model or protocol. Most of the children in that study voiced complaints and concerns about their bodies from the age of four or five, and an equal number of natal boys and girls sought help. Perhaps in those cases, prepubertal or early pubertal interventions were appropriate.
But something was different about this new group of young teens I was seeing and others who were flooding a burgeoning number of newly opened gender specialty clinics throughout the country. They didn’t present until ages eleven and beyond and often had complex mental health histories; additionally, natal girls outnumbered boys two to one. Females are significantly more represented than males in these epidemics. A 2:1 ratio of natal girls requesting gender reassignment also suggests a reaction to their relative disempowerment in patriarchal cultures, leading to increased stressors.
There was indeed something in the air: a social contagion that compelled a new group of unhappy, alienated young people to seek medical attention.
It’s not clear what role technology and physicians and therapists played in generating the epidemic. However, social and professional advocates misread the research, unfortunately conflating this new cohort, whom some have labelled “recent onset gender dysphoria” (ROGD), with the earlier Dutch children. Influenced by social contagion, it is likely this new group will, in the short term, be unhappy with the most recent social changes afoot. They are not comfortable with traditional heterosexual identities and roles. Recent surveys of older teens and twenty-somethings reveal that up to 26% do not endorse stereotypical male-female identities.
Signs of a Decline
In addition to my own office experience, there are other signs that in the last two years, interest in changing genders may be decreasing, as well as evidence that suggests a tipping point has been reached. Requests for “other” rather than male or female on new driver’s license registrations have decreased. The number of college students identifying as non-heterosexual has declined. Other surveys show rates of non-traditional identification dropping by half.
It’s hard to say how much Trump-administration-inspired discrimination and nullification have added to this shift in social mores. But in recent court decisions, medical professionals have been successfully sued for malpractice by young adults who received care and then wanted to “detransition.” Like the earlier Ramona decision, the threat of lawsuits will surely have an impact on a medical industry providing transitioning care to teens.
Even before Trump returned to the White House (and not unlike what happened forty years ago with anorexia), increased parental knowledge and empowerment began shifting the balance in how quickly teens were able to access medical interventions. Parents are more comfortable slowing their teenagers who “know” they are transgender. While the teenagers are unhappy at being restrained from getting what they think they want, the vast majority are coping without trying to kill themselves. As these young people gain experience and mature, the importance and sense of urgency for most gender transformation decreases.
Trump vs. Cancel Culture: Some Sensible Future?
As with other legitimate problems (for example, immigration and world trade), the Trump administration has bludgeoned the transgender issue, using society’s reasonable misgivings about transgirls playing in competitive sports and young teens making potentially permanent decisions about their bodies. While this delegitimization of transgender existence makes life very difficult for those who have already transitioned, liberal/left advocates who misread the signals made it very difficult for professionals like me to even raise questions without being blasted as bigots. This extremism also made it easy for the Trump administration to go on the attack, using a sense of general societal support as cover.
My guess is that this generation’s discomfort with exaggerated stereotypical sex roles in media, music, and easily accessible online pornography will continue even as the desire to change genders declines. I don’t know exactly how the next version of the alienated teen will manifest. But if the lessons of the past continue to be ignored, the same mistakes will be made again.