“But this article is not actually about cutting. If one has not yet guessed what it is really about by now, it is time for me to pull back the curtain.”
ill has an obsession with cutting herself. Do not worry; it is not life-threatening. We are talking small cuts, just minor self-mutilation. Why does she do it? I do not know. Neither does she, really. Usually, she starts feeling a bit depressed or anxious, or sometimes just angry or tense. The feeling lingers. She starts thinking about cutting herself. She knows it is not actually a good idea, that it leaves bruises, gashes and other unsightly marks, and a few times, when she went too far, it even left small but permanent scars, but the temptation keeps bubbling to the surface and is too strong to resist. The closest she can get to explaining it is that it is like an itch she knows she should not scratch because the skin is already irritated, and yet, the itch keeps itching her, and scratching it brings instantaneous release and relief. So she does it again. It satisfies her in the moment, but this time—like every other time—the sensation does not last, and regret begins to well up within her in short order. She washes away the blood and contemplates the ugly scratches on her left forearm. Although it is the middle of summer, she will have to wear a long-sleeved shirt again so that no one can see, though her mother, of course, will guess. “This would be so much easier if they didn’t stigmatize me for it,” Jill thinks with indignation, “Then, at least, I wouldn’t have to cover it up, wouldn’t have to live with the shame, wouldn’t have to take pains to conceal who I am.” It all becomes a vicious circle. Her shame and the negative judgments and condemnatory looks and words of elders and peers drive more waves of anger and depression. These add further fuel that ignites the burning itch once again. And she cuts again, and she hides again. She seethes with hatred for herself and for the world in which she is condemned to live.
Jill’s wish for public acknowledgement and acceptance will not be fulfilled anytime soon, it seems. This is not because her behavior is all that unusual. Sources report that cutting and other similar forms of self-harm may be exhibited by 4% of adults and a whopping 15% of teens, with some studies even estimating rates as high as 17-35% among college students. In spite of the widespread nature of the issue—or perhaps because of it—the most current diagnostic manual of the American Psychiatric Association, the DSM-5, added the malady to its collection when it was published in 2013. It goes by the unimaginative but apt name of “non-suicidal self-injury.” The diagnosis requires, in summary, five or more days of minor or moderate self-harm (e.g., cutting, burning, hitting, rubbing) “for purposes not socially sanctioned (e.g., body piercing, tattooing, etc.).” In addition, the behavior cannot be “of a common and trivial nature, such as picking at a wound or nail biting.” (There are other requirements—the full DSM-5 criteria for the disorder are here—but they are less material to my purposes.)
Let us imagine, however, that Jill got her wish. Imagine that cutting went from a pathology to an identity. We can conceive of the formation of a political group with a catchy name, like “Cut Off,” that begins to mobilize along the lines of its many identitarian predecessors to point us to the manner in which the stigmatization of cutting is socially constructed. Mustering academic support among sociologists to lend credibility to the cause with the requisite citations to Foucault’s Madness and Civilization and the like, they would have us note how the DSM’s very language in this case—speaking explicitly, as it does, of self-mutilation “for purposes not socially sanctioned (e.g., body piercing, tattooing, etc.)” and excluding from the definition’s scope behaviors “of a common…nature,” such as nail-biting—is tantamount to an open acknowledgment that cutting, far from an easily classifiable pathology, is fundamentally defined through its contrast with that which is “socially sanctioned” and “common.” To put it another way, cutting, despite how widespread it actually is, is not psychologically acceptable largely because it is not socially accepted. It has been abnormalized because it is not “normal.”
Cutters, they contend, are a persecuted minority whose only real crime is deviancy.
The “Cut Off” group does not stop there, of course. Much of its focus is on public outreach to showcase personal narratives highlighting harrowing tales of entirely unnecessary fear, shame and trauma that cutters like Jill experience on a daily basis due to the fact that their behavior has been medicalized and stigmatized. Cutters, they contend, are a persecuted minority whose only real crime is deviancy. The group organizes pride parades in which “out” cutters (“Cut-Outs”) display their marks of distinction openly and proudly. Gradually gaining traction, some even begin to see cutting as a form of art akin to tattooing, its accepted cousin, and start to incorporate an aesthetic motivation when the cutting compulsion comes upon them. An underground movement called “cut-art” emerges, and cut parlors begin to open up, with Cut-Outs able to engage the labor of skilled cut artists to form increasingly intricate designs that they display prominently and notoriously, sometimes even on their faces. Branding, a cut-art spin-off, employs burn patterns for the same purpose.
Eventually, the DSM-5 definition is excised, and concerned parents are pressured to recognize their cutter kids for who they are rather than trying to dissuade them from the practice. A new generation of kids grows up with Cut-Out friends, and the trending movement gains converts as kids who do not necessarily feel the psychological compulsion to cut but rather feel the more important and common (particularly among teenagers) psychological compulsion to rebel against elders join the trend. And, before long, we have a mass movement on our hands.
Not all is rosy. Cuts still subject Cut-Outs to condemnation and exclusion among some, especially older and red-state Americans. Studies expose the level of discrimination in hiring and promotion practices displayed in many workplaces (an issue brought into the open by virtue of the fact that Cut-Outs themselves are now out in the open), and courts and legislators are called upon to extend anti-discrimination protections to Cut-Outs, while employers who fall back upon the excuse of needing to hire employees who present a clean-cut (no pun intended) public face to potential customers are lambasted for relying on a cop-out earlier generations might have used to avoid hiring blacks or other minorities. What is yet more disconcerting, at least from a certain perspective, is that true Cut-Outs (those driven by compulsion rather than conformity), as reported in some studies—studies often condemned for political reasons by Cut-Out activists and the relevant academic community—still often feel a level of psychological anxiety in conjunction with their cutting, with their cuts still driven by unexpunged negative feelings of depression, anger, inadequacy, and other similar stresses. Those feelings just never seem to go away. Cut-Outs left untreated suffer from significantly far higher rates of depression, sociopathic tendencies, painkiller addiction and other substance abuse and, ultimately, suicide than their “normal” peers.
While cutting is real, classified in the DSM-5 and just as widespread as I have said, it is, of course, not (yet) an identity group, and if an identity movement of the sort I have described were to coalesce, most of us would find it crazy, a normalization of what is all-too-obviously a disorder. But this article is not actually about cutting. If one has not yet guessed what it is really about by now, it is time for me to pull back the curtain.
One might never know it from the glut of hysterical press coverage the issue receives, but, unlike those engaging in self-harm, the transgendered are a teeny, tiny minority, a mere 0.6% of adults and a very slightly higher percentage of teens. (As Abigail Shrier’s Irreversible Damage (2020) has documented, even this number reflects a massive, unprecedented surge since 2015, particularly among teen girls, in those identifying as transgendered.) The DSM-IV had contained a diagnosis entitled “gender identity disorder.” Significant political pressure had demanded the declassification of the “disorder,” but countervailing considerations of allowing for treatment covered by insurance and keeping intact the protections offered by anti-discrimination laws militated in the opposite direction. This 2010 discussion from the AMA Journal of Ethics summarized the issues in play:
“The challenge presented with gender identity and sexual behaviors is that we lack a clear definition of ‘normal,’ from either a biological or psychological standpoint. This generates a moving target for pathology, which is therefore in need of ongoing review and discussion.”
With regard to gender identity disorder, a parallel to homosexuality has been used to argue for the elimination of this disorder from the DSM. Homosexuality was removed over the course of revisions to the DSM in the 1970s and ’80s due to pressure from both inside and outside the APA…”
Similar arguments are being made for removing GID, namely that continued labeling of expressions of gender as pathological is discriminatory and perpetuates stigma, causing harm to transgender individuals…There is growing evidence that the increased incidence of psychiatric problems in transsexual individuals is related to stigma and that many individuals have nonclinical levels of distress or impairment…”
“One important argument in favor of keeping a gender identity disorder in the DSM is the concern that its removal would lead to denial of medical care for transgender individuals, hamper their ability to pursue discrimination claims, and deprive people, including children, with GID of the counseling and medical treatments demonstrated to be beneficial, which will likely continue to require a psychiatric assessment for justification.”
Ultimately, the compromise reached by the drafters of the DSM-5 was to replace “gender identity disorder” with a new category entitled “gender dysphoria.” As explained by a gender clinic director and pediatric endocrinologist, “The new diagnosis recognized that a mismatch between one’s birth gender and identity was not necessarily pathological. It shifted the emphasis in treatment from fixing a disorder to resolving distress over the mismatch.”
The change in nomenclature and the well-publicized politicization of the issue that began to exert enormous pressure on parents and practitioners to help those suffering from gender dysphoria to transition to their gender of choice rather than to attempt to assuage the feeling of dysphoria on a psychological level, however, did not change the reality that individuals afflicted with gender dysphoria experience a high degree of negative emotion and negative life outcomes. Critically, this remains true even after the process of transitioning was complete, as a Swedish study of long-term outcomes documented, showing—among other things—that post-transition individuals have a nearly 20% higher rate of suicides than the general population. A summary of the state of affairs on this issue in The Guardian, not exactly a conservative publication, aptly encapsulates the research in this area:
“Guardian Weekend” asked Birmingham University’s Aggressive Research Intelligence Facility (Arif) to assess the findings of more than 100 follow-up studies of post-operative transsexuals. Arif, which conducts reviews of healthcare treatments for the NHS, concludes that none of the studies provides conclusive evidence that gender reassignment is beneficial for patients. It found that most research was poorly designed, which skewed the results in favor of physically changing sex. There was no evaluation of whether other treatments, such as long-term counseling, might help transsexuals, or whether their gender confusion might lessen over time.
I would suggest that this outcome should in no way surprise anyone who has ever spent any time interacting with a child: Whether the issue is career choice or sexuality, kids repeatedly change their minds.
In 2016, while President Barack Obama was still in the White House, the Centers for Medicare & Medicaid Services arrived at a similar conclusion in considering—and denying—a request that all gender reassignment surgery be covered by Medicare:
“Overall, the quality and strength of evidence were low due to mostly observational study designs with no comparison groups, subjective endpoints, potential confounding (a situation where the association between the intervention and outcome is influenced by another factor such as a co-intervention), small sample sizes, lack of validated assessment tools, and considerable lost to follow-up.”
(See also here.) Still more strikingly, the same memo found “the four best designed and conducted studies that assessed quality of life before and after surgery using validated (albeit non-specific) psychometric studies did not demonstrate clinically significant changes or differences in psychometric test results after [gender reassignment surgery].”
Complicating the picture still further is a much-publicized paper in the journal PLOS One by Brown University professor, physician and researcher Lisa Littman, which found that a good bit of social contagion was afoot in the transgender tumult. Identifying the disturbing phenomenon of “rapid-onset gender dysphoria,” Littman studied 256 teens that had come out as transgender after a childhood with no signs of gender dysphoria and reported that prior to coming out as transgender, 86% of the teens (the majority of whom had at least one other mental disorder) had either shown increased use of social media or had had one or multiple friends come out before them. Predictably, the paper received massive pushback from transgender activists and their allies, occasioning an embarrassing display of academic cowardice on the part of Brown University, but, in the end, the paper was reissued with only minimal cosmetic revisions and its fundamental conclusions unaltered.
The final critical piece of this puzzle is that gender dysphoria in children and teens—if not indulged through medical interventions to transform the body—often resolves itself. A range of studies shows that between 60% and 90% of kids suffering from gender dysphoria grow up to be ordinary gay and lesbian adults. I would suggest that this outcome should in no way surprise anyone who has ever spent any time interacting with a child: Whether the issue is career choice or sexuality, kids repeatedly change their minds. It is normal for kids and teens to be playful, experimental, gender-bending, boundary-crossing, and thoroughly and entirely confused about the meaning of new thoughts and sensations, especially when it comes to the sexual realm. Most grow out of it.
The bottom-line problem is that—on a conceptual level—the belief that one is “really” a different gender than the one that corresponds with the body into which one is born is not much different from any other delusional belief that one is actually someone else. It is certainly easier, in some ways, not to fight a delusional belief with years of patience, therapy and/or medication but instead, especially in the short term, to give in to it and rearrange one’s life to indulge the fantasy. See, e.g., Max Frisch’s 1954 novel, I’m Not Stiller. That, however, is generally not the approach to such issues that we as a society adopt because, in the long term, it almost always proves more satisfying and within the realm of realistic possibility to change one’s mind than to transform’s one’s body and one’s world.
Inevitably, the unsettling cautionary tale of conversion therapy for homosexuals comes to mind. It is an inapt analogy. Homosexuality is a sexual preference. It requires willing partners, and it requires—in an ideal world—a tolerant society, but it does not require drastic surgical interventions and a lifetime of hormonal treatment in pursuit of an unattainable outcome that still leaves so many people unsatisfied, even to the point of being suicidal.
And so we return to the subject of my fantasia of a far closer analogy: the cutters. Like transsexuals, they pursue bodily mutilation to assuage psychological unrest. Like transsexuals, their mutilation never brings them the final comfort they seek. But, unlike transsexuals, the cutters’ minor cuts and scrapes generally do not involve serious surgeries, permanent changes, a long uphill battle against nature waged with the help of an experimental course of life-long hormones with significant side effects (see Table 11), ranging from severe liver disfunction to breast cancer, potentially irreversible loss of fertility and unpredictable impacts on the ability to feel sexual satisfaction. If anything, therefore, the cutters—who, again, far outnumber the transgendered—can make a more compelling plea to be reclassified from a pathology to an identity.
If I have demonstrated anything at all here, it is that the question of what counts as a DSM-classifiable psychiatric condition vs. an identity group in need of acceptance and recognition is complicated and necessarily intertwined with our society’s norms, philosophical issues, and technological ones as well—for if our technology allowed us to press a few buttons to change feelings or change bodies, it would all be a matter of choice, and there would be no vexed and difficult question to resolve. If there is anything else I hope to have demonstrated, it is that we must not hop on bandwagons or jump to conclusions.
The plight of those who, regardless of the reason, begin to feel like their bodies are not their own should be met with nothing but compassion, oodles of compassion. But feeling and showing compassion are one thing, while doing the compassionate thing is another. The latter requires deliberation, and giving people—especially impulsive children and teens, whose identities are just beginning to coalesce and who may not gain a more solid grasp of who they are and/or want to be for another decade or more—easy access to exactly what they want in the moment is unlikely to be the best solution. A wait-and-see approach is surely preferable when drastic fixes are being considered and when so much is at stake. On the other hand, the worst thing we could possibly do is to politicize the issue, summoning up the shrillest and most intolerant voices on both sides. If, instead of discussing how a small minority of people struggling with a significant psychological issue can best be helped, we are debating bathrooms and pronouns, fighting over “misgendering” and forcing biological females to compete in races or on wrestling mats against biological males rather than discussing effective treatment options, the debate is over, and we have all lost. Everyone is screaming, no one is listening, and rash decisions dictated by anger and fear are driving us all ever closer to a sociocultural precipice.
Alexander Zubatov is a lawyer in New York, as well as an essayist and poet.