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Dr. Cheryl Green: What’s Ailing Young Women

The most common precursor of gender dysphoria, though, seems to be intense social media use. The gender dysphoria more often seems to stem from that rather than from the home.”

Cheryl L. Green M.D., the author of the 2023 book Heal Your Daughter: How Lifestyle Psychiatry Can Save Her from Depression, Cutting, and Suicidal Thoughts and the accompanying Heal Your Daughter Workbook: Six Weeks to Feeling Good with Lifestyle Psychiatry, responded to a series of questions from Merion West’s Emeline Torrens about what she is seeing in her patients, most of whom are adolescent girls in the Los Angeles area. Dr. Green earned an undergraduate degree at Harvard College and a Ph.D. at Princeton University prior to graduating from Stanford University School of Medicine in 2011. Dr. Green is an assistant professor of psychiatry at Loma Linda University School of Medicine in Southern California in addition to seeing patients in private practice. Her works tends to emphasize positive lifestyle changes. Merion West released an excerpt from her book in April of this year. In her responses below, Dr. Green touches on gender dysphoria, anxiety and depression in young people, and how the problem has become more acute in recent years. 

As we have seen, “diagnoses of youths with gender dysphoria” have been surging over the past few years in the United States, from 15,172 in 2017 to 42,167 in 2021, according to data from Komodo Health Inc. This has also attracted significant media attention, much of it polarized. Based on what you’re seeing day to day in your practice, do these statistics reflect reality?

Yes. I have noticed trends in my practice toward greater anxiety, greater depression, more cutting, and definitely more gender dysphoria. Teens used to worry about their sexual preference; now, many teens are wondering about their gender identity, instead. The whole sexual preference issue seems to have receded into the background. Many of my teen patients say that they are asexual or pansexual without seeming to think too much about it. Yet, they seem to be worrying a lot about what gender identity they might want to adopt. Many worry about this for a number of years and flip back and forth several times before making a “final” decision. But “final” is a relative term, it seems.

I’m not sure that the increase in gender dysphoria has to do with the news media so much as social media, with its charismatic young leaders, its positive reinforcements—likes, hearts, and so on. I suspect that it also has to do with the form of gender education that they practice in the schools right now, where one is required to “choose” a gender from a large menu of possibilities, only one of which is cis. Choosing cis is actually called “gender conformity.” Conformity is a term that carries a negative valence, a negative connotation. No young person wants to be labeled as a “conformist.” So the big PR firms on Madison Avenue, who are in charge of the nomenclature, have made a large impact here. The word (or words) you use to name a thing in the press and in the educational curriculum have everything to do with whether people think of that thing as good or bad; normal or strange; acceptable or unacceptable.

In your recent book, you suggest that contemporary society is bedeviled by the “Stockholm syndrome of modernity.” Given what we know about Stockholm syndrome, how aware are patients when it comes to identifying what is contributing to their unhappiness and/or dysregulation?

I don’t think that teens—or, for that matter, we adults—really know the precise recipe for any one teen’s depression or dysregulation. But, in general, we do know that teens are subject to historically high levels of stress, drug use, family problems, bullying, social media use, poor diet, lack of time outdoors, lack of exercise, lack of sleep due to excessive homework requirements or for other reasons. Then, there’s the lack of real-world social connections, as well as many other ills that modern life has subjected them to. Teens do bond with (and map onto) the culture of their peers at school and of their generation generally: onto the music, the video games, the school curriculum, the social mores including permissiveness around drugs and sex, ventures onto the dark web, etc. A lot of all this is actually traumatizing to teens and tweens.

Regarding your experiences as a private practitioner on the proverbial frontlines of the gender revolution, has there been any collective sense of, “Who allowed me to do this to myself” among those detransitioning?

Many patients come to me who are transitioning with their endocrinologist, and some come to me detransitioning. For those transitioning, generally there is quite a bit of medical and legal support. For detransitioners, there generally is not as much medical or legal support. For example, it is illegal for a psychiatrist to try to help a patient to return to his or her natal gender even if they want to—illegal, that is, to provide what is defined as gender-conforming treatment. I have encountered young people who changed their minds about having a trans identity, some even after more than a decade of identifying as transgendered. For several of those people, the sentiment toward the parents was actually: “Thank God that you didn’t let me do anything to myself.” That is, now that I’m cis gendered, or a TERF (i.e., a trans-exclusionary radical feminist), or whatever it may be. You can talk about that with a patient so long as you don’t actually recommended reverting to his or her original gender. I have not personally encountered a teen who transitioned, regretted it, then later blamed his or her parents for allowing the transition to occur. But I have read about and watched on video many such cases in the media. For example, there is a widely circulated film called The Detransition Diaries, on this topic.

How does one reconcile healthcare, administering care properly, and politics?

As to the political and social stuff, there are varying degrees of “wokeness” in the psychiatric community. Some are all in, while others find it utterly ridiculous, sad, and/or disturbing. There is a trend for the views to correspond to age, younger psychiatrists being more “woke,” and older psychiatrists being less “woke” or even “anti-woke.” But it is not considered politically correct today for a psychiatrist to hold the latter views. When personal ethics go one way, and medical case law goes the other way, the best a psychiatrist can do is to explain the laws that they are obliged to follow to the patient and his or her family and then transfer the patient to a peer who does not have ethical difficulties with those laws.

Given the impassioned discourse around gender as of late, has there been any ideological seism within healthcare? Is there a risk of practicing healthcare as an expression of politics vs. healthcare as healthcare?

Legally, a psychiatrist can’t say anything negative to a patient about a patient’s decision to transition to a non-natal gender. It is considered unethical for a psychiatrist to perform what has been termed “gender-conforming” treatment. Many parents request that the psychiatrist do that, but if the psychiatrist were to provide that type of treatment, he or she would run the risk of losing his or her medical license. This fact is on the main Psychiatry Board exam for licensure, so all psychiatrists-in-training either are acutely aware of this or should be. Psychologists follow similar laws. They are required to provide “gender-affirming” treatment—that is, to affirm the gender chosen most recently by the patient, whether it corresponds to the natal gender or not.

Given your holistic approach, would you argue that there is a tendency too frequently to pathologize patients? For instance, what might be simply a terrible home environment and poor coping mechanisms is immediately labeled as “clinical depression.”

This is a great question. I had a mentor once who joked that there are actually only three diagnoses in child and adolescent psychiatry: “bad” brain, “fried” brain, and “terrible” parents, though he used a more colorful term to describe the parents. He was referring to genetic disorders, disorders as a result of illicit drug use, and disorders stemming from mediocre parenting. But the DSM, which is our main text that defines and describes psychiatric disorders, doesn’t actually address root causes at all. I can tell you that teen depression is real, and I suspect that it is likely under-diagnosed rather than over-diagnosed. CDC’s recent report, the Youth Risk Behavior Survey, puts rates at 57% for high school girls: more than half. But the cause of depression varies in each child or teen. Sometimes, it is one of the above causes. But trauma or crime, such as sexual assault, is another cause. Isolation or rejection by peers can cause it. School failure can cause it. Confusion, or too rapid change of any kind, can cause it. According to the CDC’s report, the LGBT community, too, is actually at greater risk than the norm for depression. So many of our high school students really are suffering, even if they manage to keep up appearances. In my opinion, the root causes of a given teen’s depression need to be identified and then appropriately addressed. Sometimes, actual changes in the teen’s life are needed. Sometimes, legal action is needed for that teen to begin to feel whole. For these types of healing, the caregivers, whether parents or other family members, such as grandparents, do need to step up.

Arguably, it seems as though we’ve entered—quite oxymoronically—the “society of the individual” and though there is unrivaled emphasis on one’s own uniqueness and diversity, there are staggering levels of unhappiness. How should one reconcile the two coinciding trends and/or contextualize the trend in response to technology?

I agree that the young individual, who is supposed to be “special” and unique in every way, like a rock star, is exalted in American culture. I think this does place a lot of stress on teens to perform in some strange, ill-defined, sometimes totally unspecified way. And I agree that this forces teens to have supremely high expectations of themselves that, alas, they are probably going to fail to meet. And, yes, technology is encouraging this cult of specialness. We have not only extreme sports but now also extreme beauty, extreme brilliance, extreme everything, as the standard. Why haven’t you made your first million dollars by age 20? Where is your academy award? Everyone looks fabulous on Instagram, or Facebook, or wherever. The warts and body odor are strangely missing. And, of course, there is no reality there. Somehow, we have lost humility as a cultural value. Being simple, straightforward, humble, and just nice: Those are values from the last century, it seems.

In an increasingly technologically dependent society—combined with social media and a ceaseless news cycle—how have you seen identity, empowerment, and personal agency change? Have they been weakened? 

Another great question. I would say, yes, the sense of empowerment and the sense of personal agency have definitely decreased. Many of our youth seem hypnotized or appear to be in a state of learned helplessness. They no longer plan to go out and “conquer the world.” They just want to survive the next new thing that is coming at them, whether it’s a virus, or global warming, or economic collapse, or whatever. They are in a defensive posture, most definitely. They are trying to adapt to increasingly abnormal “norms.”

Where would you say is the biggest conflict in messaging and support? Do the divisions—and sometimes, antagonisms—still stand between the home and school environment; the social and the political?

The conflicts I see that are most devastating to teens are those between divorcing parents. Most divorces contain elements of parental alienation—that is, the situation in which the parents whether deliberately or inadvertently cause the child to hate the other parent. That truly traumatizes children. I have rarely seen a divorce that did not totally traumatize the children, because of the parental alienation. “Your mother is evil.” Or, “Your father is evil.” That really messes with a child’s sense of identity, with his or her earliest memories, and with his or her head generally, even if it’s largely true. It is a more immediate and potent type of damage than school messaging or socioeconomics or politics alone could inflict.

Next, I think would be the influence of a best friend or romantic partner, for example, if that friend or partner becomes suicidal. That can become almost like a contagion. And third would be the influence of the media the teen consumes. A lot of what is out there is inherently traumatizing to my teen patients. Certain lyrics of songs. Certain acts they must perform in video games. Certain things they witness on television. Pornography with its overt and subliminal messaging, or whatever. Many teens are traumatized by the culture of “their” generation, though, of course, that “culture” is engineered primarily by adults. The media and the educational system are driving the culture, but who is driving the media and education, and why is the messaging all so negative and/or confusing?

Historically, what have been prevailing themes or precursors of unhappiness and/or dysphoria? Are young adults from stress-free homes equally vulnerable?

The themes preceding unhappiness are ever-changing. What I used to see a lot of on the inpatient unit 15 years ago was: Girl falls in love with boy; girl sleeps with boy; boy dumps girl; girl tries to commit suicide. But, now, that is actually a fairly rare presentation. More common than that is: Girl or boy consumes a lot of social media, starts isolating from all real people, starts cutting, and tries to commit suicide. Or, girl or boy consumes a lot of cannabis, becomes psychotic (that is, starts behaving in a bizarre or paranoid way), and is brought into the ER by police. Or, boy starts taking large amounts of illicit drugs, becomes violent with parents, and is brought into the ER by police. I would say that those are the most common presentations on the inpatient unit today.

In the outpatient world, the themes preceding unhappiness could be literally anything. The most common precursor of gender dysphoria, though, seems to be intense social media use. The gender dysphoria more often seems to stem from that rather than from the home. But it’s no easy task to remove social media from a teen’s life. There is FOMO, the “fear of missing out,” and there is a need, it seems, for teens to make social comparisons with one another, even if those comparisons are painful for them.

Taking a cell phone away from a teenager would be far more difficult than it would be to take candy away from a baby–not that anyone would do that. Most teens are addicted to their smartphones. The tendency to escalate one’s use of the cell phone is real, and the withdrawal symptoms when the phone is taken away are also real. Few people would have anticipated this problem prior to 2007. But since teens with flip phones, which are the main alternative, are ridiculed by their peers, we are still struggling to find a good solution to the problem. The depression and the dysphoria among our teens are at record levels. We, in psychiatry, are struggling to find solutions. I do believe that the best solutions right now are coming from lifestyle psychiatrists. That is why I wrote Heal Your Daughter—so that parents can learn some techniques that have a chance of saving their teens.

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