Are you considering online therapy? The internet has opened up new avenues for mental health treatment, but there are some pros and cons that you should consider before you decide if e-therapy is right for you. Let’s explore some of the biggest advantages and disadvantages of online therapy.
Advantages of Online Therapy
1. A Good Option for Remote Areas
Online therapy offers access to mental health information to people in rural or remote areas.
Those who live in such areas simply might not have access to any other form of mental health treatment because there are no mental health practices in their geographic area. E-therapy gives these individuals access to treatment that they might not have otherwise.
2. Accessibility for Those With Physical Limitations
Online therapy provides accessibility to individuals who are disabled or housebound. Mobility can be a big issue when it comes to accessing mental health care. Individuals who are unable to leave their home for various reasons, such as physical or mental illness, may find online therapy a useful alternative to traditional psychotherapy settings.
3. Convenience and Affordability
Online therapy is usually fairly affordable and convenient. Since you will be attending therapy sessions online in the comfort of your own home, you can often schedule your therapy sessions for times that are the most convenient for you.
Today, many states require insurance providers to cover online therapy just as they would traditional therapy sessions. Contact your insurance company to learn more about e-therapy treatments will be covered by your policy. Online therapists often offer affordable treatment options for those who are not covered by health insurance.
4. Online Therapy Makes Information More Accessible
The Internet makes mental health information more accessible. People may feel comfortable talking to friends and family about health care issues but may not feel the same discussing mental health concerns.
5. It Can Also Be an Educational Tool
E-therapy can be an important tool to help people learn more about psychological health. Even if you feel like your mental well-being is strong, online therapy can help you become psychologically stronger. You can learn more about health behaviors and coping strategies that will lead to better psychological health.
Disadvantages of Online Therapy
1. Some Insurance Companies Will Not Cover E-Therapy
Insurance coverage for e-therapy can depend upon the state where you live and the insurance that you have. Some insurance policies do not cover online therapy. Paying for psychotherapy services out-of-pocket can add up quickly.
2. Some States Do Not Allow Out-of-State Providers
Many states do not allow out-of-state psychologists to provide services. In such cases, you provider would need to be licensed in both their home state as well as your home state.
In an article for the Monitor on Psychology, Deborah Baker, a legal expert for the American Psychological Association, explained that some states allow psychologists to provide out-of-state mental health services for a limited amount of time.
This usually consists of just 10 to 30 days per year.
However, psychologists can practice online therapy with clients in their own state, which can be a great option for those who live at a distance, are housebound, or who need access to convenient treatment options.
3. Concerns About Confidentiality, Privacy, and Unreliable Technology
Keeping your personal information private is a major concern in psychotherapy, but online treatment adds a layer of complexity. Confidentiality is just as important in online therapy as it is in more traditional forms of treatment delivery. Since information is being transmitted online, it makes privacy leaks and hacks more of a concern.
Technology problems can also make it difficult to access treatment when you really need it.
4. Online Therapists Cannot Respond to Crisis Situations
Since online therapists are distant from the client, it is difficult to respond quickly and effectively when a crisis happens. If a client is experiencing suicidal thoughts or has suffered a personal tragedy, it can be difficult or even impossible for the therapist to provide direct assistance.
5. Online Therapy is Not Appropriate for Those with Serious Psychiatric Illnesses
E-therapy can be useful for a variety of situations, but not when it comes to more serious psychiatric illnesses that require close and direct treatment. It is also not appropriate for people with complicated or detailed problems. The scope of-therapy tends to be limited, so it is rarely effective in more complex situations.
6. Online Therapy Sometimes Lacks Important Information
In many cases, online therapists cannot see facial expressions, vocal signals, or body language. These signals can often be quite telling and give the therapist a clearer picture of your feelings, thoughts, moods, and behaviors. Some delivery methods such as voice-over-Internet technology and video chats can provide a clearer picture of the situation, but they often lack the intimacy and intricacy that real-world interactions possess.
7. Ethical and Legal Concerns Pose Potential Problems
Online therapy eliminates geographic restraints, making the enforcement of legal and ethical codes difficult. Therapists can treat clients from anywhere in the world, and many states have different licensing requirements and treatment guidelines. It is important to understand your therapist's qualifications and experience before you begin the treatment process.
How Much Online Therapy Really Goes On?
This great article from Gregory Mulhauser of CounselingResource.com looks at the ethical challenges posed by therapists and their experience with online therapy.
Emailing Your Doctor or Therapist
Learn more about some of the issues surrounding the use of e-mail communications between therapists and clients, from your About Guide to Mental Health Resources.
References
DeAngelis, T. (2012). Practice distance therapy, legally and ethically. Monitor on Psychology, 43(3), 52. Retrieved from http://www.apa.org/monitor/2012/03/virtual.aspx.
Hoffman, J. (2011, Sept. 23). When your therapist is only a click away. The New York Times. Retrieved from http://www.nytimes.com/2011/09/25/fashion/therapists-are-seeing-patients-online.html.
Posted by: Dan L. Boen, Ph.D. AT 11:30 am
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Hi. I'm Blaise ₍⸍⸌̣ʷ̣̫⸍̣⸌₎ I like cats more than I like people. Stigma Fighter & Mental Health Advocate Destigmatizing Borderline Personality Disorder.
Borderline Personality Disorder is one of the most misunderstood, stigmatised & complex mental health diagnoses.
One could write pages relating to the condition BPD and a layman’s understanding would still be incomplete.
For this reason I am going to try and keep it short, simple and concise as I can and explain to you what BPD is to me.
BPD is intense feelings of loneliness & an inability to sit with myself without resorting to poor coping behaviours.
BPD is extreme emotional vulnerability & sensitivity. Feelings of severe internal distress are triggered easily.
BPD causes a slow return to my baseline. This means strong emotions & cognitions tend to take a long time to dissipate.
BPD feels like I am ‘dying inside’ immense emotional turbulence & pain, distress beyond explanation.
BPD is feeling as though my emotions are so impossible to live with that they will surely kill me. Most of the time it feels as though my emotions are in control of me and I am not in control of my emotional world.
BPD is impulsive behaviours and an inability to ‘think before I act’ and ‘learn from my mistakes’ time and time again.
BPD is extreme & rapid mood swings ranging from periods of depression to somewhat dysphoric & delusional bouts of mania.
BPD is paranoia and anxiety, especially in interpersonal circumstances.
Problems with ‘attachment’ especially with authority & care-giver figures e.g. therapists, teachers, etc.
A history of suicidal ideation, tendencies & threats. Multiple short & long-term admissions to A&E, hospital and crisis houses.
Risk-taking & thrill-seeking behaviours as well as chronic boundary-pushing & rule-breaking, especially with authority.
Self-destructive tendencies, especially self-injurious behaviour mostly through cutting. This has also manifested through eating disordered behaviours, alcohol & drug abuse. Others may struggle with sex, spending, gambling & other addictive behaviours.
Lack of sense of self. Having to define myself based on my external world & lacking a fundamental secure sense of a ‘true me’, only being able to have an idea of who I am by looking at evidence & cues in the people & world around me. Only being able to have an idea of who I am by looking at evidence & cues in the people & world around me.
BPD is depersonalisation (feeling as though I do not exist, am not in my body & am not in control of thoughts/actions).
Difficulties with appropriately expressing my anger often leading to heightened displays & outbursts of intense pent-up emotion.
A highly severe guilt & shame complex in response to every imperfect interaction or perceived personal failure.
Feelings of self-hatred, self-loathing, hopelessness, despair, especially in response to making mistakes that impact others.
Black-and-white thinking as well as the tendency to engage in catastrophic thinking, mind-reading & jumping to conclusions.
High perceptiveness of people and circumstances around me, to the point of unhealthy & paranoid hyper-vigilance.
Feelings of being misunderstood by the world & people around me & of never fitting in, always being on a different wave-length.
Splitting: Rapidly changing perceptions of myself & people around me from one extreme to the other.
Finally manipulative behaviours such as playing people in my life off against each other. Asking multiple people the same thing until I receive the answer I am looking for, convolutedly threatening self-destructive.
I wouldn’t be like this if I knew how to not be like this. When you’re fighting BPD, you’re fighting a silent battle. No one sees how hard you’re constantly having to fight your mind.
People with the diagnosis of BPD need to be heard. We are all too often silenced by services & professionals.
People with BPD are not a bunch of stereotypes. We have emotions, feelings, dreams like everyone else. We just feel too deeply.
Living with BPD or people who have it is a blessing and learning curve in itself. Stay patient, focus and appreciative.
People with BPD are many things. Often loving, kind, passionate, creative, determined, giving, ambitious, brave and caring.
The stigma around BPD is so wrong. 99% of the people I’ve come in to contact with are absolutely loving, giving and caring.
For more information and support, follow my Twitter BPDBanter
Hi. I'm Blaise ₍⸍⸌̣ʷ̣̫⸍̣⸌₎ I like cats more than I like people. Stigma Fighter & Mental Health Advocate Destigmatizing Borderline Personality Disorder.
The concept of schizophrenia is dying. Harried for decades by psychology, it now appears to have been fatally wounded by psychiatry, the very profession that once sustained it. Its passing will not be mourned.
Part of the problem turns out to be the concept of schizophrenia itself.
Arguments that schizophrenia is a distinct disease have been “fatally undermined.” Just as we now have the concept of autism spectrum disorder, psychosis (typically characterized by distressing hallucinations, delusions, and confused thoughts) is also argued to exist along a continuum and in degrees. Schizophrenia is the severe end of a spectrum or continuum of experiences.
Jim van Os, a professor of psychiatry at Maastricht University, has argued that we cannot shift to this new way of thinking without changing our language. As such, he proposes the term schizophrenia “should be abolished.” In its place, he suggests the concept of a psychosis spectrum disorder.
Another problem is that schizophrenia is portrayed as a “hopeless chronic brain disease.” As a result, some people given this diagnosis, and some parents, have been told cancer would have been preferable, as it would be easier to cure. Yet this view of schizophrenia is only possible by excluding people who do have positive outcomes. For example, some who recover are effectively told that “it mustn’t have been schizophrenia after all.”
Schizophrenia, when understood as a discrete, hopeless and deteriorating brain disease, argues van Os, “does not exist.”
I expect to see the end of the concept of schizophrenia soon...the syndrome is already beginning to breakdown, for example, into those cases caused by copy number [genetic] variations, drug abuse, social adversity, etc. Presumably this process will accelerate, and the term “schizophrenia” will be confined to history, like “dropsy.”
Research is now exploring the different ways people may end up with many of the experiences deemed characteristic of schizophrenia: hallucinations, delusions, disorganized thinking and behavior, apathy and flat emotion.
Indeed, one past error has been to mistake a path for the path or, more commonly, to mistake a back road for a motorway. For example, based on their work on the parasite Toxoplasma gondii, which is transmitted to humans via cats, researchers E. Fuller Torrey and Robert Yolken have argued that “the most important etiological agent [cause of schizophrenia] may turn out to be a contagious cat.” It will not.
Evidence does suggest that exposure to Toxoplasma gondii when young can increase the odds of someone being diagnosed with schizophrenia. However, the size of this effect involves less than a twofold increase in the odds of someone being diagnosed with schizophrenia. This is, at best, comparable to other risk factors, and probably much lower.
Compared with noncannabis users, the daily use of high-potency, skunk-like cannabis is associated with a fivefold increase in the odds of someone developing psychosis. Compared with someone who has not suffered trauma, those who have suffered five different types of trauma (including sexual and physical abuse) see their odds of developing psychosis increase more than 50-fold.
Other routes to “schizophrenia” are also being identified. Around 1 percent of cases appear to stem from the deletion of a small stretch of DNA on chromosome 22, referred to as 22q11.2 deletion syndrome. It is also possible that a low single digit percentage of people with a schizophrenia diagnosis may have their experiences grounded in inflammation of the brain caused by autoimmune disorders, such as anti-NMDA receptor encephalitis, although this remains controversial.
All the factors above could lead to similar experiences, which we in our infancy have put into a bucket called schizophrenia. One person’s experiences may result from a brain disorder with a strong genetic basis, potentially driven by an exaggeration of the normal process of pruning connections between brain cells that happens during adolescence. Another person’s experiences may be due to a complex post-traumatic reaction. Such internal and external factors could also work in combination.
Either way, it turns out that the two extreme camps in the schizophrenia wars—those who view it as a genetically-based neurodevelopmental disorder and those who view it as a response to psychosocial factors, such as adversity—both had parts of the puzzle. The idea that schizophrenia was a single thing, reached by a single route, contributed to this conflict.
Implications for treatment
Many medical conditions, such as diabetes and hypertension, can be reached by multiple routes that nevertheless impact the same biological pathways and respond to the same treatment. Schizophrenia could be like this. Indeed, it has been argued that the many different causes of schizophrenia discussed above may all have a common final effect: increased levels of dopamine.
If so, the debate about breaking schizophrenia down by factors that lead to it would be somewhat academic, as it would not guide treatment. However, there is emerging evidence that different routes to experiences currently deemed indicative of schizophrenia may need different treatments.
Preliminary evidence suggests that people with a history of childhood trauma who are diagnosed with schizophrenia are less likely to be helped by antipsychotic drugs. However, more research into this is needed and, of course, anyone taking antipsychotics should not stop taking them without medical advice. It has also been suggested that if some cases of schizophrenia are actually a form of autoimmune encephalitis, then the most effective treatment could be immunotherapy (such as corticosteroids) and plasma exchange (washing of the blood).
Yet the emerging picture here is unclear. Some new interventions, such as the family-therapy based Open Dialogue approach, show promise for a wide range of people with schizophrenia diagnoses. Both general interventions and specific ones, tailored to someone’s personal route to the experiences associated with schizophrenia, may be needed. This makes it critical to test for and ask people about all potentially relevant causes. This includes childhood abuse, which is still not being routinely asked about and identified.
The potential for different treatments to work for different people further explains the schizophrenia wars. The psychiatrist, patient or family who see dramatic beneficial effects of antipsychotic drugs naturally evangelically advocate for this approach. The psychiatrist, patient or family who see drugs not working, but alternative approaches appearing to help, laud these. Each group sees the other as denying an approach that they have experienced to work. Such passionate advocacy is to be applauded, up to the point at which people are denied another approach that may work for them.
What comes next?
None of this is to say the concept of schizophrenia has no use. Many psychiatrists still see it as a useful clinical syndrome that helps define a group of people with clear health needs. Here it is viewed as defining a biology that is not yet understood but which shares a common and substantial genetic basis across many patients.
Some people who receive a diagnosis of schizophrenia will find it helpful. It can help them access treatment. It can enhance support from family and friends. It can give a name to the problems they have. It can indicate they are experiencing an illness and not a personal failing. Of course, many do not find this diagnosis helpful. We need to retain the benefits and discard the negatives of the term schizophrenia, as we move into a post-schizophrenia era.
What this will look like is unclear. Japan recently renamed schizophrenia as “integration disorder.” We have seen the idea of a new “psychosis spectrum disorder.” However, historically, the classification of diseases in psychiatry has been argued to be the outcome of a struggle in which “the most famous and articulate professor won.” The future must be based on evidence and a conversation that include the perspectives of people who suffer—and cope well with—these experiences.
Whatever emerges from the ashes of schizophrenia, it must provide better ways to help those struggling with very real experiences.
Editor’s Note: Every whiff you take not only brings a cloud of chemicals swirling up your nose, but matters to your experience of taste as well as smell. Scientists studying smell have not only provided compelling evidence that it’s more sophisticated than previously thought, but believe that the sense of smell impacts our mood and behavior and has the potential to detect and treat some neurological disorders. Compared to other senses, smell has long been underappreciated, writes our author, but that is now beginning to change.
Illustration by William Hogan
In many ways, the sense of smell—also known as olfaction (from the Latin word for smell or odor, olfactorius)—is our most complex sensory system, capable of distinguishing thousands, if not millions, of different odors, often at concentrations below those detectable by sophisticated instruments. The biological machinery required for such a feat is remarkable, involving six to ten million odorant receptor cells embedded within a thin layer of tissue (epithelium) high in the nasal chambers. Each receptor cell projects 10 to 30 thread-like cilia into the mucus covering the epithelium (see figure 1 below).
These cilia carry receptors—protein structures specialized to respond to odor-carrying molecules, termed odorants. There are nearly 400 types of receptors, different subsets of which are triggered by different odorants. Each of the olfactory receptor cells contains only one type of receptor. When enough odorant molecules get through the mucus layer and bind to the receptors located on the receptor cell cilia, they stimulate a neural impulse. The pattern of activated receptors is specific to a given odorant, and the neural impulses that are generated are decoded by higher brain regions. Memory processes also become involved, allowing us to recognize odor sensations of which we are familiar.
The major breakthrough for understanding the first phase of olfactory transduction came in 1991 when Linda Buck and Richard Axel at Columbia University published their seminal paper identifying the gene family responsible for the expression of the olfactory receptors.1 Their work, which led to the 2004 Nobel Prize in Medicine or Physiology, put to rest questions as to the nature of initial olfactory transduction that had puzzled scientists for hundreds of years.
Since then the situation has become much more complex, with ever more types of receptors being found on some olfactory receptor cells,2 and the realization that olfactory receptors are present in tissues throughout the body. These include the skin,3 skeletal muscle,4 thyroid,5 heart,6 lungs,7 pancreas,8 thymus,9 prostate,10 kidney,11 bladder,9 testes,5 intestine,12 blood vessels,13 and ganglia of the autonomic nervous system.13 Their widespread distribution raises the question of whether these receptors should, indeed, be called “olfactory.“ Depending upon their location, they are involved in many biological and physiological processes, including glucose homeostasis, lung ventilation, regulation of blood pressure, mitigation of tumor progression, promotion of angiogenesis, facilitation of sperm motility, induction of wound healing, and alteration of gut motility and secretion.14 Understanding the role of such receptors in these diverse processes is opening new vistas for novel pharmacological approaches to disease management and treatment.
The Underrated Sense
Although most of us take our sense of smell for granted, it is critical for our well-being. We use olfaction to verify the cleanliness of our clothes and homes, and to fully enjoy foods, beverages, personal care products, flowers, and other aspects of our environment. Without a sense of smell, we are exposed to the dangers of spoiled food, leaking natural gas, burning electrical wires, smoke, and other environmental hazards. The sense of smell is so important that those who can’t smell (anosmics) are disqualified for “appointment, enlistment, and induction” into the US Armed Forces. Indeed, the lack of smell ability can be the basis for retirement or discharge.15
Multiple factors influence our ability to smell. These include occupation (e.g., perfumers and master sommeliers perform better than most of us on olfactory tests), sex, age, exercise, smoking, nutrition, head trauma, disease, and exposures to viruses, bacteria, and xenobiotics.16 The influence of age on smell function is particularly salient. More than three-quarters of individuals over the age of 80 have a demonstrable smell problem, usually reduced sensitivity.17 This decrease is illustrated below (see Figure 2 below), where a major drop occurs in later life in scores on the University of Pennsylvania Smell Identification Test (UPSIT), a 40-odor smell test developed at our center in the early 1980s (Figure 3).18 (Note in Figure 2 that women, on average, outperform men on this test and maintain their superiority into later life.) Over the age of 85 years, 40 percent of men and 26 percent of women are anosmic, i.e., have no sense of smell at all.19
Figure 2. University of Pennsylvania Smell Identification (UPSIT) scores as a function of age and sex. Note that women identify odorants better than men at all ages although significant overlap occurs. Numbers by data points indicate sample sizes. (From Doty and colleagues.17 Copyright 1984 American Association for the Advancement of Science.)
It is noteworthy that many patients who come to our center’s clinic for evaluation and treatment do not recognize that they have a smell problem, complaining only of a “taste” problem. However, when we formally test them, their ability to smell proves to be the culprit. Why? Because the taste buds, located throughout the oral cavity but primarily on the tongue, sense only sweet, sour, bitter, salty, and savory (“umami) sensations. Everything else we think of as taste, such as strawberry, apple, chocolate, coffee, butterscotch, meat sauce, and apple pie, are really flavors that depend upon the sense of smell.
This is easily demonstrated. The next time you sip your coffee, pinch your nose closed while swishing the coffee around in your mouth. You will notice the bitterness of the coffee, its warmth and smoothness, but not the distinctive coffee flavor. Indeed, the sensation is much like swishing bitter hot water. The reason why the coffee “taste” disappears is that, by holding your nose shut, you block the flow of coffee flavor molecules from the rear of the oral cavity to the olfactory receptors via the nasopharyx, the opening from the mouth into the nose.
I was once asked to visit a large retirement home to better understand why there was concern about bad tasting food. The situation was quite dire, since some residents had largely refused to eat the food and a few were wasting away. Such turmoil arose around this issue that many of the residents were on a campaign to have the chef fired. The chef eventually quit, but the problem continued even after a new chef had come on board. I had the opportunity to give a lecture to 100 or so of the residents on nutrition and the chemical senses, and passed out the UPSIT for them to take immediately after my talk. It was at this time that most of the residents discovered they could not smell very well, with most exhibiting hyposmia (decreased smell function), and that the problem with the institution’s food was largely in their noses, not in the kitchen!
Smelling Danger
Aside from altered perception of the flavor of foods and attendant nutritional issues, the loss of smell function that most of us experience in our later years has potentially lethal consequences. This is evidenced by the disproportionate number of elderly people who have died in accidental gas poisonings, in part because of their inability to detect the odor added as a safety factor to natural gas.20 Most of us have, at some time in our lives, used this sense to avert a danger from something burning on the stove, a smoldering wire in an electrical outlet, or gas from a stove that was not completely turned off. In a study of over 1,000 persons conducted by the Medical College of Virginia, anosmics were three times more likely than those with a normal sense of smell to report having experienced a potentially life-threatening event such as the ingestion of spoiled food or a failure to detect smoke or leaking natural gas.21
Recent studies suggest that smell loss is an extremely strong risk factor for death in healthy older persons, increasing the odds of dying by more than 300 percent over a four-to five-year period.22 Although the reasons behind the association have yet to be determined, smell loss is a stronger predictor of death than cognitive deficits, cancer, stroke, lung disease, or hypertension, even after controlling for sex, age, race, education, socioeconomic status, smoking behavior, cardiovascular disease, diabetes, and liver damage.22, 23
Independent of age, we now know that smell dysfunction heralds the onset of a number of neurological diseases, including Alzheimer’s and Parkinson’s diseases.24 In some cases, such dysfunction occurs years, even decades, before the appearance of the classic disease symptoms. The olfactory bulb—a structure at the base of the brain that receives information from the olfactory receptor neurons—is among the two brain regions that first show disease-related pathology in Parkinson’s disease.25 Although damage to the olfactory bulb also occurs in early Alzheimer’s disease, some studies suggest that disrupted connections between the olfactory cortex and the hippocampus, which is involved in memory, predate it.25 Factors including damage to neurotransmitter systems critical for olfactory function may precede the development of the neuropathology of such diseases, possibly even catalyzing disease development itself.26
Impact on Memory
We and others have observed a close relationship between the ability to smell and memory: older persons with olfactory loss are more likely to report difficulties in memory.27 In a study of 1,092 non-demented elderly persons (average age 80 years) from a multi-ethnic community in New York, UPSIT scores varied with the degree of memory impairment and with performance on a number of cognitive tests.28 Importantly, such scores were weakly correlated with the MRI-determined volume of the hippocampus, a brain structure intimately associated with memory.
Numerous longitudinal studies have demonstrated that olfactory deficits are associated with future cognitive decline and Alzheimer’s disease in older populations.29 Moreover, interactions with genetics have also been demonstrated. In 1999, Amy Bornstein Graves and her associates at the University of South Florida published a pioneering study in which a 12-odor version of the UPSIT was administered to 1,604 community-dwelling senior citizens. None initially showed any signs of dementia.30 The smell test scores were found to be a better predictor of cognitive decline over the study’s two-year period than scores on a global cognitive test. Persons with normal smell function who carried one or two APOE-4 alleles (a risk factor for Alzheimer’s disease) had only a slight elevation in risk of developing cognitive decline. However, anosmic carriers of such alleles had a five-fold risk in developing cognitive decline during this time period. While this risk was approximately three-fold in men, it was nearly 10-fold in women.
Close relatives of patients with Alzheimer’s disease appear to have poorer smell function than non-relatives of the same sex and age, implying that genetic factors may be at play.31 However, the potential influences of interactions between environmental factors and genes, including the APOE-4 allele, cannot be overlooked. Using the UPSIT, Calderon-Garciduenas and her colleagues in Mexico City found olfactory dysfunction in 35.5 percent of 62 young persons (average age 21 years) living in a highly polluted area of that city, as compared to only 12 percent of those living in a much less polluted city.32 Interestingly, APOE-4 carriers from the polluted areas failed to identify 24 percent on the 10 items reported to be particularly sensitive to Alzheimer’s disease,33 whereas carriers of the APOE 2/3 and 3/3 alleles, which are not risk factors for Alzheimer’s disease, failed only 13.6 percent of such items, suggesting that AOE-4 gene carriers are more susceptible to adverse influences of pollution on their olfactory pathways.
Association with Parkinson’s
In the 1990s, G. Webster Ross and his collaborators at the University of Hawaii administered the 12-item version of the UPSIT to 2,276 non-symptomatic elderly men (average age: 80) of Japanese ancestry.34 Over the next four years, 35 were clinically diagnosed with Parkinson’s disease, a disorder whose motor dysfunction is due to damage to areas of the brain that employ the neurotransmitter dopamine for motor control. After adjusting for age, smoking behavior, and other confounders, those persons whose initial olfactory test scores fell within the bottom 25 percent of the group were five times more likely to develop Parkinson’s disease than those whose test scores fell within the top 25 percent.
Additional support for early olfactory involvement in Parkinson’s disease came from a 2004 study performed at the Vrije Universiteit (VU University) in Amsterdam. In this study, olfactory tests were administered to 361 asymptomatic first-degree relatives of Parkinson’s disease patients.35 The health of regions of the brain involved in motor control also was determined using single photon emission tomography (SPECT) imaging. This procedure measures the concentration of dopamine transporter, the protein responsible for returning the neurotransmitter into cells after its release into the synaptic cleft (see Figure 4). Those with the best (top 10 percent) and worse (bottom 10 percent) olfactory test scores were followed over time to determine who developed Parkinson’s disease.
Figure 5: Imaging of the dopamine receptor in patients with Parkinson’s disease (PD) (Right) and age-and sex matched normal controls (Left). Note the depletion of the radioactively labelled ligand sensitive to the dopamine transporter in the PD subjects relative to the controls. Photograph courtesy of Jacob Dubroff, Smell and Taste Center and Department of Neuroradiology, University of Pennsylvania.
Two years into the study, four of the 40 relatives (10 percent) with the worst olfactory test scores developed clinical Parkinson’s disease, whereas none of the 38 relatives with the best test scores did. By five years, the incidence among relatives rose to 12.5 percent. Only those from the poor-smelling group evidenced decreased imaging of the dopamine transporter and, in some cases, such decreases were evident at baseline, suggesting that subclinical disease had already begun. These data suggested that the risk of developing Parkinson’s disease in the presence of hyposmia may be as high as 22 percent in first-degree relatives.35
Numerous other studies support the view that olfactory testing may be helpful in predicting the development of cognitive and motor disorders.24 Indeed, olfactory dysfunction rivals and even exceeds the sensitivity of a number of other biomarkers in such prediction, including SPECT imaging of the dopamine transporter,36 as described above. Currently, novel methods are being developed to enhance the predictive power of olfactory tests. For example, spraying the inside of the nose with atropine, a drug that accentuates cognitive dysfunction in patients with Alzheimer’s disease via its anticholinergic effects, may induce a greater degree of smell loss in individuals who are at risk for future dementia, in effect “unmasking” the disease.37
Although quantitative smell testing is rarely performed by most physicians, it has been found to be useful in not only detecting, but also discriminating among, a number of neurodegenerative diseases. For example, a disorder called progressive supranuclear palsy (PSP) is often misdiagnosed as Parkinson’s disease. Unlike Parkinson’s, however, patients with PSP have a relatively normal sense of smell.38 Thus, a neurologist whose evaluation of such a person is inconclusive can use smell testing to aid in making the correct diagnosis. The same is true for distinguishing between depression and Alzheimer’s disease, with depressed patients showing little evidence of smell loss.39 In a position paper, the quality standards committee of the American Academy of Neurology has in fact recommended that olfactory testing be considered to differentiate Parkinson’s disease from PSP and corticobasal degeneration, another neurological disorder.40
Keeping Your Sense of Smell Sharp
How can each of us maintain a healthy sense of smell? All through life, viruses, air pollutants, and other environmental toxins cumulatively damage receptor cells In the uppermost regions of our noses. Such cumulative damage is not manifested until later in life, when few cells are left to provide a normal sense of smell. Hence, the degree to which we can minimize exposure to such agents, such as having good air filters in our homes and washing our hands regularly, can go a long way in preventing damage.
Maintaining good sleep patterns also protects smell function. Obstructive sleep apnea, in particular, has been associated with smell loss,41 which may be attenuated by the use of a CPAP (continuous positive airway pressure) machine at night.42 Importantly, daily exercise has been shown to help avert age-related decrements in the ability to smell.43 It may even help preserve olfaction in persons with Parkinson’s disease.44
Aside from maintaining good health via exercise, sleep, and avoidance of pathogens, a healthy diet and certain dietary interventions may also help. Gopinath and associates at the University of Sydney compared the odor identification ability of 1331 persons who differed in terms of their dietary intake of nuts, fish, butter, and margarine.45 Those with the most nut and fish consumption had a reduced likelihood of olfactory loss, possibly because of the anti-inflammatory properties of these foods‘ constituents. Similarly, Richard Stevenson and his colleagues at Macquarie University in Sydney found that persons who ate a Western style diet high in saturated fat and sugar exhibited poorer odor identification test scores than those whose diets were low in these nutrients.46
Conversely, an impaired sense of smell may lead to dietary changes that ultimately impact health, as evidenced by a study at Yale University that assessed dietary habits in 80 elderly women, 37 of whom had olfactory dysfunction.47 The latter exhibited a nutrient intake profile that increases the chances for cardiac disease, including a higher intake of sweets and a lower preference for citrus fruits.
A Tie to Coffee
My own colleagues and I showed, in 2007, that the lifetime history of coffee drinking was positively associated with UPSIT scores in relatives of patients with Parkinson’s disease.48 Thus, after correcting for age, gender, and tobacco use, the mean UPSIT score for those who drank less than one cup a day was 30.4 (out of a possible 40); for those who drank one cup a day it was 32.6, while for those who drank two to three cups a day or four or more cups a day the mean scores were 33.1 and 34.1, respectively. This pattern was statistically significant (p < 0.009) and was stronger in men than in women. Whether the same relationship may be found in the general population has yet to be determined.
Looking Forward
What does the future hold? In Japan, a major pharmaceutical company has begun an initiative to educate physicians about the importance of this primary sensory system and to distribute olfactory tests via pharmacies to promote better understanding of the health of the Japanese elderly population. In light of recent discoveries, it is inevitable that more and more physicians will begin to pay attention to the smell ability of their patients, and to routinely test this faculty.
Given that olfactory receptors are not just confined to the nose, future research will establish whether smell testing can provide information on the distribution of olfactory receptors elsewhere in the body and indicate whether such information may aid in the detection and treatment of some genetic-related diseases. More research on how odors influence mood and behavior is underway, and novel devices for adding odors to the environment are in development.
Just as we largely control our auditory environment, we may soon be able to engineer our olfactory environment in a much more sophisticated way, to alter our states of mind and improve our mental health. The future of olfactory research seems on target to fulfill the prescient assessment of Alexander Graham Bell in a 1927 Scientific Monthly article: “Odors are becoming more and more important in the world of scientific experiments and in medicine—and the need for more knowledge of odors will bring more knowledge, as surely as the sun shines.”
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More comfortable online than out partying, post-Millennials are safer, physically, than adolescents have ever been. But they’re on the brink of a mental-health crisis.
One day last summer, around noon, I called Athena, a 13-year-old who lives in Houston, Texas. She answered her phone—she’s had an iPhone since she was 11—sounding as if she’d just woken up. We chatted about her favorite songs and TV shows, and I asked her what she likes to do with her friends. “We go to the mall,” she said. “Do your parents drop you off?,” I asked, recalling my own middle-school days, in the 1980s, when I’d enjoy a few parent-free hours shopping with my friends. “No—I go with my family,” she replied. “We’ll go with my mom and brothers and walk a little behind them. I just have to tell my mom where we’re going. I have to check in every hour or every 30 minutes.”
Those mall trips are infrequent—about once a month. More often, Athena and her friends spend time together on their phones, unchaperoned. Unlike the teens of my generation, who might have spent an evening tying up the family landline with gossip, they talk on Snapchat, the smartphone app that allows users to send pictures and videos that quickly disappear. They make sure to keep up their Snapstreaks, which show how many days in a row they have Snapchatted with each other. Sometimes they save screenshots of particularly ridiculous pictures of friends. “It’s good blackmail,” Athena said. (Because she’s a minor, I’m not using her real name.) She told me she’d spent most of the summer hanging out alone in her room with her phone. That’s just the way her generation is, she said. “We didn’t have a choice to know any life without iPads or iPhones. I think we like our phones more than we like actual people.”
I’ve been researching generational differences for 25 years, starting when I was a 22-year-old doctoral student in psychology. Typically, the characteristics that come to define a generation appear gradually, and along a continuum. Beliefs and behaviors that were already rising simply continue to do so. Millennials, for instance, are a highly individualistic generation, but individualism had been increasing since the Baby Boomers turned on, tuned in, and dropped out. I had grown accustomed to line graphs of trends that looked like modest hills and valleys. Then I began studying Athena’s generation.
Around 2012, I noticed abrupt shifts in teen behaviors and emotional states. The gentle slopes of the line graphs became steep mountains and sheer cliffs, and many of the distinctive characteristics of the Millennial generation began to disappear. In all my analyses of generational data—some reaching back to the 1930s—I had never seen anything like it.
At first I presumed these might be blips, but the trends persisted, across several years and a series of national surveys. The changes weren’t just in degree, but in kind. The biggest difference between the Millennials and their predecessors was in how they viewed the world; teens today differ from the Millennials not just in their views but in how they spend their time. The experiences they have every day are radically different from those of the generation that came of age just a few years before them.
What happened in 2012 to cause such dramatic shifts in behavior? It was after the Great Recession, which officially lasted from 2007 to 2009 and had a starker effect on Millennials trying to find a place in a sputtering economy. But it was exactly the moment when the proportion of Americans who owned a smartphone surpassed 50 percent.
The more I pored over yearly surveys of teen attitudes and behaviors, and the more I talked with young people like Athena, the clearer it became that theirs is a generation shaped by the smartphone and by the concomitant rise of social media. I call them iGen. Born between 1995 and 2012, members of this generation are growing up with smartphones, have an Instagram account before they start high school, and do not remember a time before the internet. The Millennials grew up with the web as well, but it wasn’t ever-present in their lives, at hand at all times, day and night. iGen’s oldest members were early adolescents when the iPhone was introduced, in 2007, and high-school students when the iPad entered the scene, in 2010. A 2017 survey of more than 5,000 American teens found that three out of four owned an iPhone.
The advent of the smartphone and its cousin the tablet was followed quickly by hand-wringing about the deleterious effects of “screen time.” But the impact of these devices has not been fully appreciated, and goes far beyond the usual concerns about curtailed attention spans. The arrival of the smartphone has radically changed every aspect of teenagers’ lives, from the nature of their social interactions to their mental health. These changes have affected young people in every corner of the nation and in every type of household. The trends appear among teens poor and rich; of every ethnic background; in cities, suburbs, and small towns. Where there are cell towers, there are teens living their lives on their smartphone.
To those of us who fondly recall a more analog adolescence, this may seem foreign and troubling. The aim of generational study, however, is not to succumb to nostalgia for the way things used to be; it’s to understand how they are now. Some generational changes are positive, some are negative, and many are both. More comfortable in their bedrooms than in a car or at a party, today’s teens are physically safer than teens have ever been. They’re markedly less likely to get into a car accident and, having less of a taste for alcohol than their predecessors, are less susceptible to drinking’s attendant ills.
Psychologically, however, they are more vulnerable than Millennials were: Rates of teen depression and suicide have skyrocketed since 2011. It’s not an exaggeration to describe iGen as being on the brink of the worst mental-health crisis in decades. Much of this deterioration can be traced to their phones.
Even when a seismic event—a war, a technological leap, a free concert in the mud—plays an outsize role in shaping a group of young people, no single factor ever defines a generation. Parenting styles continue to change, as do school curricula and culture, and these things matter. But the twin rise of the smartphone and social media has caused an earthquake of a magnitude we’ve not seen in a very long time, if ever. There is compelling evidence that the devices we’ve placed in young people’s hands are having profound effects on their lives—and making them seriously unhappy.
In the early 1970s, the photographer Bill Yates shot a series of portraits at the Sweetheart Roller Skating Rink in Tampa, Florida. In one, a shirtless teen stands with a large bottle of peppermint schnapps stuck in the waistband of his jeans. In another, a boy who looks no older than 12 poses with a cigarette in his mouth. The rink was a place where kids could get away from their parents and inhabit a world of their own, a world where they could drink, smoke, and make out in the backs of their cars. In stark black-and-white, the adolescent Boomers gaze at Yates’s camera with the self-confidence born of making your own choices—even if, perhaps especially if, your parents wouldn’t think they were the right ones.
Fifteen years later, during my own teenage years as a member of Generation X, smoking had lost some of its romance, but independence was definitely still in. My friends and I plotted to get our driver’s license as soon as we could, making DMV appointments for the day we turned 16 and using our newfound freedom to escape the confines of our suburban neighborhood. Asked by our parents, “When will you be home?,” we replied, “When do I have to be?”
But the allure of independence, so powerful to previous generations, holds less sway over today’s teens, who are less likely to leave the house without their parents. The shift is stunning: 12th-graders in 2015 were going out less often than eighth-graders did as recently as 2009.
Today’s teens are also less likely to date. The initial stage of courtship, which Gen Xers called “liking” (as in “Ooh, he likes you!”), kids now call “talking”—an ironic choice for a generation that prefers texting to actual conversation. After two teens have “talked” for a while, they might start dating. But only about 56 percent of high-school seniors in 2015 went out on dates; for Boomers and Gen Xers, the number was about 85 percent.
The decline in dating tracks with a decline in sexual activity. The drop is the sharpest for ninth-graders, among whom the number of sexually active teens has been cut by almost 40 percent since 1991. The average teen now has had sex for the first time by the spring of 11th grade, a full year later than the average Gen Xer. Fewer teens having sex has contributed to what many see as one of the most positive youth trends in recent years: The teen birth rate hit an all-time low in 2016, down 67 percent since its modern peak, in 1991.
Even driving, a symbol of adolescent freedom inscribed in American popular culture, from Rebel Without a Cause to Ferris Bueller’s Day Off, has lost its appeal for today’s teens. Nearly all Boomer high-school students had their driver’s license by the spring of their senior year; more than one in four teens today still lack one at the end of high school. For some, Mom and Dad are such good chauffeurs that there’s no urgent need to drive. “My parents drove me everywhere and never complained, so I always had rides,” a 21-year-old student in San Diego told me. “I didn’t get my license until my mom told me I had to because she could not keep driving me to school.” She finally got her license six months after her 18th birthday. In conversation after conversation, teens described getting their license as something to be nagged into by their parents—a notion that would have been unthinkable to previous generations.
Independence isn’t free—you need some money in your pocket to pay for gas, or for that bottle of schnapps. In earlier eras, kids worked in great numbers, eager to finance their freedom or prodded by their parents to learn the value of a dollar. But iGen teens aren’t working (or managing their own money) as much. In the late 1970s, 77 percent of high-school seniors worked for pay during the school year; by the mid-2010s, only 55 percent did. The number of eighth-graders who work for pay has been cut in half. These declines accelerated during the Great Recession, but teen employment has not bounced back, even though job availability has.
Of course, putting off the responsibilities of adulthood is not an iGen innovation. Gen Xers, in the 1990s, were the first to postpone the traditional markers of adulthood. Young Gen Xers were just about as likely to drive, drink alcohol, and date as young Boomers had been, and more likely to have sex and get pregnant as teens. But as they left their teenage years behind, Gen Xers married and started careers later than their Boomer predecessors had.
Gen X managed to stretch adolescence beyond all previous limits: Its members started becoming adults earlier and finished becoming adults later. Beginning with Millennials and continuing with iGen, adolescence is contracting again—but only because its onset is being delayed. Across a range of behaviors—drinking, dating, spending time unsupervised— 18-year-olds now act more like 15-year-olds used to, and 15-year-olds more like 13-year-olds. Childhood now stretches well into high school.
Why are today’s teens waiting longer to take on both the responsibilities and the pleasures of adulthood? Shifts in the economy, and parenting, certainly play a role. In an information economy that rewards higher education more than early work history, parents may be inclined to encourage their kids to stay home and study rather than to get a part-time job. Teens, in turn, seem to be content with this homebody arrangement—not because they’re so studious, but because their social life is lived on their phone. They don’t need to leave home to spend time with their friends.
If today’s teens were a generation of grinds, we’d see that in the data. But eighth-, 10th-, and 12th-graders in the 2010s actually spend less time on homework than Gen X teens did in the early 1990s. (High-school seniors headed for four-year colleges spend about the same amount of time on homework as their predecessors did.) The time that seniors spend on activities such as student clubs and sports and exercise has changed little in recent years. Combined with the decline in working for pay, this means iGen teens have more leisure time than Gen X teens did, not less.
So what are they doing with all that time? They are on their phone, in their room, alone and often distressed.
One of the ironies of iGen life is that despite spending far more time under the same roof as their parents, today’s teens can hardly be said to be closer to their mothers and fathers than their predecessors were. “I’ve seen my friends with their families—they don’t talk to them,” Athena told me. “They just say ‘Okay, okay, whatever’ while they’re on their phones. They don’t pay attention to their family.” Like her peers, Athena is an expert at tuning out her parents so she can focus on her phone. She spent much of her summer keeping up with friends, but nearly all of it was over text or Snapchat. “I’ve been on my phone more than I’ve been with actual people,” she said. “My bed has, like, an imprint of my body.”
In this, too, she is typical. The number of teens who get together with their friends nearly every day dropped by more than 40 percent from 2000 to 2015; the decline has been especially steep recently. It’s not only a matter of fewer kids partying; fewer kids are spending time simply hanging out. That’s something most teens used to do: nerds and jocks, poor kids and rich kids, C students and A students. The roller rink, the basketball court, the town pool, the local necking spot—they’ve all been replaced by virtual spaces accessed through apps and the web.
You might expect that teens spend so much time in these new spaces because it makes them happy, but most data suggest that it does not. The Monitoring the Future survey, funded by the National Institute on Drug Abuse and designed to be nationally representative, has asked 12th-graders more than 1,000 questions every year since 1975 and queried eighth- and 10th-graders since 1991. The survey asks teens how happy they are and also how much of their leisure time they spend on various activities, including nonscreen activities such as in-person social interaction and exercise, and, in recent years, screen activities such as using social media, texting, and browsing the web. The results could not be clearer: Teens who spend more time than average on screen activities are more likely to be unhappy, and those who spend more time than average on nonscreen activities are more likely to be happy.
There’s not a single exception. All screen activities are linked to less happiness, and all nonscreen activities are linked to more happiness. Eighth-graders who spend 10 or more hours a week on social media are 56 percent more likely to say they’re unhappy than those who devote less time to social media. Admittedly, 10 hours a week is a lot. But those who spend six to nine hours a week on social media are still 47 percent more likely to say they are unhappy than those who use social media even less. The opposite is true of in-person interactions. Those who spend an above-average amount of time with their friends in person are 20 percent less likely to say they’re unhappy than those who hang out for a below-average amount of time.
If you were going to give advice for a happy adolescence based on this survey, it would be straightforward: Put down the phone, turn off the laptop, and do something—anything—that does not involve a screen. Of course, these analyses don’t unequivocally prove that screen time causes unhappiness; it’s possible that unhappy teens spend more time online. But recent research suggests that screen time, in particular social-media use, does indeed cause unhappiness. One study asked college students with a Facebook page to complete short surveys on their phone over the course of two weeks. They’d get a text message with a link five times a day, and report on their mood and how much they’d used Facebook. The more they’d used Facebook, the unhappier they felt, but feeling unhappy did not subsequently lead to more Facebook use.
Social-networking sites like Facebook promise to connect us to friends. But the portrait of iGen teens emerging from the data is one of a lonely, dislocated generation. Teens who visit social-networking sites every day but see their friends in person less frequently are the most likely to agree with the statements “A lot of times I feel lonely,” “I often feel left out of things,” and “I often wish I had more good friends.” Teens’ feelings of loneliness spiked in 2013 and have remained high since.
This doesn’t always mean that, on an individual level, kids who spend more time online are lonelier than kids who spend less time online. Teens who spend more time on social media also spend more time with their friends in person, on average—highly social teens are more social in both venues, and less social teens are less so. But at the generational level, when teens spend more time on smartphones and less time on in-person social interactions, loneliness is more common.
So is depression. Once again, the effect of screen activities is unmistakable: The more time teens spend looking at screens, the more likely they are to report symptoms of depression. Eighth-graders who are heavy users of social media increase their risk of depression by 27 percent, while those who play sports, go to religious services, or even do homework more than the average teen cut their risk significantly.
Teens who spend three hours a day or more on electronic devices are 35 percent more likely to have a risk factor for suicide, such as making a suicide plan. (That’s much more than the risk related to, say, watching TV.) One piece of data that indirectly but stunningly captures kids’ growing isolation, for good and for bad: Since 2007, the homicide rate among teens has declined, but the suicide rate has increased. As teens have started spending less time together, they have become less likely to kill one another, and more likely to kill themselves. In 2011, for the first time in 24 years, the teen suicide rate was higher than the teen homicide rate.
Depression and suicide have many causes; too much technology is clearly not the only one. And the teen suicide rate was even higher in the 1990s, long before smartphones existed. Then again, about four times as many Americans now take antidepressants, which are often effective in treating severe depression, the type most strongly linked to suicide.
What’s the connection between smartphones and the apparent psychological distress this generation is experiencing? For all their power to link kids day and night, social media also exacerbate the age-old teen concern about being left out. Today’s teens may go to fewer parties and spend less time together in person, but when they do congregate, they document their hangouts relentlessly—on Snapchat, Instagram, Facebook. Those not invited to come along are keenly aware of it. Accordingly, the number of teens who feel left out has reached all-time highs across age groups. Like the increase in loneliness, the upswing in feeling left out has been swift and significant.
This trend has been especially steep among girls. Forty-eight percent more girls said they often felt left out in 2015 than in 2010, compared with 27 percent more boys. Girls use social media more often, giving them additional opportunities to feel excluded and lonely when they see their friends or classmates getting together without them. Social media levy a psychic tax on the teen doing the posting as well, as she anxiously awaits the affirmation of comments and likes. When Athena posts pictures to Instagram, she told me, “I’m nervous about what people think and are going to say. It sometimes bugs me when I don’t get a certain amount of likes on a picture.”
Girls have also borne the brunt of the rise in depressive symptoms among today’s teens. Boys’ depressive symptoms increased by 21 percent from 2012 to 2015, while girls’ increased by 50 percent—more than twice as much. The rise in suicide, too, is more pronounced among girls. Although the rate increased for both sexes, three times as many 12-to-14-year-old girls killed themselves in 2015 as in 2007, compared with twice as many boys. The suicide rate is still higher for boys, in part because they use more-lethal methods, but girls are beginning to close the gap.
These more dire consequences for teenage girls could also be rooted in the fact that they’re more likely to experience cyberbullying. Boys tend to bully one another physically, while girls are more likely to do so by undermining a victim’s social status or relationships. Social media give middle- and high-school girls a platform on which to carry out the style of aggression they favor, ostracizing and excluding other girls around the clock.
Social-media companies are of course aware of these problems, and to one degree or another have endeavored to prevent cyberbullying. But their various motivations are, to say the least, complex. A recently leaked Facebook document indicated that the company had been touting to advertisers its ability to determine teens’ emotional state based on their on-site behavior, and even to pinpoint “moments when young people need a confidence boost.” Facebook acknowledged that the document was real, but denied that it offers “tools to target people based on their emotional state.”
In July 2014, a 13-year-old girl in North Texas woke to the smell of something burning. Her phone had overheated and melted into the sheets. National news outlets picked up the story, stoking readers’ fears that their cellphone might spontaneously combust. To me, however, the flaming cellphone wasn’t the only surprising aspect of the story. Why, I wondered, would anyone sleep with her phone beside her in bed? It’s not as though you can surf the web while you’re sleeping. And who could slumber deeply inches from a buzzing phone?
Curious, I asked my undergraduate students at San Diego State University what they do with their phone while they sleep. Their answers were a profile in obsession. Nearly all slept with their phone, putting it under their pillow, on the mattress, or at the very least within arm’s reach of the bed. They checked social media right before they went to sleep, and reached for their phone as soon as they woke up in the morning (they had to—all of them used it as their alarm clock). Their phone was the last thing they saw before they went to sleep and the first thing they saw when they woke up. If they woke in the middle of the night, they often ended up looking at their phone. Some used the language of addiction. “I know I shouldn’t, but I just can’t help it,” one said about looking at her phone while in bed. Others saw their phone as an extension of their body—or even like a lover: “Having my phone closer to me while I’m sleeping is a comfort.”
It may be a comfort, but the smartphone is cutting into teens’ sleep: Many now sleep less than seven hours most nights. Sleep experts say that teens should get about nine hours of sleep a night; a teen who is getting less than seven hours a night is significantly sleep deprived. Fifty-seven percent more teens were sleep deprived in 2015 than in 1991. In just the four years from 2012 to 2015, 22 percent more teens failed to get seven hours of sleep.
The increase is suspiciously timed, once again starting around when most teens got a smartphone. Two national surveys show that teens who spend three or more hours a day on electronic devices are 28 percent more likely to get less than seven hours of sleep than those who spend fewer than three hours, and teens who visit social-media sites every day are 19 percent more likely to be sleep deprived. A meta-analysis of studies on electronic-device use among children found similar results: Children who use a media device right before bed are more likely to sleep less than they should, more likely to sleep poorly, and more than twice as likely to be sleepy during the day.
Electronic devices and social media seem to have an especially strong ability to disrupt sleep. Teens who read books and magazines more often than the average are actually slightly less likely to be sleep deprived—either reading lulls them to sleep, or they can put the book down at bedtime. Watching TV for several hours a day is only weakly linked to sleeping less. But the allure of the smartphone is often too much to resist.
Sleep deprivation is linked to myriad issues, including compromised thinking and reasoning, susceptibility to illness, weight gain, and high blood pressure. It also affects mood: People who don’t sleep enough are prone to depression and anxiety. Again, it’s difficult to trace the precise paths of causation. Smartphones could be causing lack of sleep, which leads to depression, or the phones could be causing depression, which leads to lack of sleep. Or some other factor could be causing both depression and sleep deprivation to rise. But the smartphone, its blue light glowing in the dark, is likely playing a nefarious role.
The correlations between depression and smartphone use are strong enough to suggest that more parents should be telling their kids to put down their phone. As the technology writer Nick Bilton has reported, it’s a policy some Silicon Valley executives follow. Even Steve Jobs limited his kids’ use of the devices he brought into the world.
What’s at stake isn’t just how kids experience adolescence. The constant presence of smartphones is likely to affect them well into adulthood. Among people who suffer an episode of depression, at least half become depressed again later in life. Adolescence is a key time for developing social skills; as teens spend less time with their friends face-to-face, they have fewer opportunities to practice them. In the next decade, we may see more adults who know just the right emoji for a situation, but not the right facial expression.
I realize that restricting technology might be an unrealistic demand to impose on a generation of kids so accustomed to being wired at all times. My three daughters were born in 2006, 2009, and 2012. They’re not yet old enough to display the traits of iGen teens, but I have already witnessed firsthand just how ingrained new media are in their young lives. I’ve observed my toddler, barely old enough to walk, confidently swiping her way through an iPad. I’ve experienced my 6-year-old asking for her own cellphone. I’ve overheard my 9-year-old discussing the latest app to sweep the fourth grade. Prying the phone out of our kids’ hands will be difficult, even more so than the quixotic efforts of my parents’ generation to get their kids to turn off MTV and get some fresh air. But more seems to be at stake in urging teens to use their phone responsibly, and there are benefits to be gained even if all we instill in our children is the importance of moderation. Significant effects on both mental health and sleep time appear after two or more hours a day on electronic devices. The average teen spends about two and a half hours a day on electronic devices. Some mild boundary-setting could keep kids from falling into harmful habits.
In my conversations with teens, I saw hopeful signs that kids themselves are beginning to link some of their troubles to their ever-present phone. Athena told me that when she does spend time with her friends in person, they are often looking at their device instead of at her. “I’m trying to talk to them about something, and they don’t actually look at my face,” she said. “They’re looking at their phone, or they’re looking at their Apple Watch.” “What does that feel like, when you’re trying to talk to somebody face-to-face and they’re not looking at you?,” I asked. “It kind of hurts,” she said. “It hurts. I know my parents’ generation didn’t do that. I could be talking about something super important to me, and they wouldn’t even be listening.”
Once, she told me, she was hanging out with a friend who was texting her boyfriend. “I was trying to talk to her about my family, and what was going on, and she was like, ‘Uh-huh, yeah, whatever.’ So I took her phone out of her hands and I threw it at my wall.”
I couldn’t help laughing. “You play volleyball,” I said. “Do you have a pretty good arm?” “Yep,” she replied.
What I Needed From the Church During My Depression
3 ways our communities can support mental health.
Alicia Cohn | posted August 3, 2016
Image: Milos Kreckovic / iStock
Speaking at the Democratic National Convention last week, the singer Demi Lovato took advantage of the powerful platform to advocate for mental health care in America. “Like millions of Americans, I am living with mental illness,” she said. "Too many Americans from all walks of life don't get help, either because they fear the stigma or they cannot afford treatment."
“Mental illness” is a scary-sounding category that encompasses a broad array of invisible struggles. Look around you on Sunday. Most likely, there are Christians next to you suffering silently from anxiety or panic disorder, bipolar disorder (from which Lovato suffers), dysthymia or major depressive disorder (from which I have suffered). Whether through personal experience or through someone we know, those of us whose lives have been touched by mental health struggles know that getting help can be the hardest part.
Women are twice as likely to experience mental health struggles as men, thanks to major hormonal challenges such as pregnancy and menstruation. According to the Centers for Disease Control and Prevention (CDC), 30 percent of women between 18 and 44 years of age are affected by depression, and many of them don’t get the help they need. (My own disorder went undiagnosed for almost six months before I got help from doctors and therapy, and even then, the recovery process has been hindered by bad advice, mistreatment, and poor choices about whom I can rely on.)
Unfortunately, many of us who have spoken up in church communities have been told to “pray harder” or “have more faith.” These suggestions might be well intentioned, but they often discourage and isolate those of us in desperate need of support. “It’s a knee-jerk reaction to judge people when they’re vulnerable,” wrote actress Kristen Bell of her own story. “But there’s nothing weak about struggling with mental illness. You’re just having a harder time living in your brain than other people.”
She’s right: Struggling with an illness of any kind makes a person vulnerable, and a sick brain puts a person in a particularly vulnerable state because it’s often impossible to discern the problem from the inside. The sick brain can’t see the sick brain. More often than not, someone in the midst of a depressive episode or panic attack can barely put forth a cry for help.
As people living in Christian community, we should be ready to offer practical knowledge and gracious support to people experiencing mental health crises. With that in mind, here are three ways I believe every church is best positioned to help:
Faith in something better.
“Have faith that on the other side of your pain is something good,” Dwayne “The Rock” Johnson told the Oprah Presents Master Class. He wished someone had relayed this idea to him during a low point in his life when he was “crying constantly.” His message mirrors the “It gets better” campaign, but many people suffering from depression or other mental health issues know that sometimes it gets worse. Everyone needs a reason to keep trying. I’ve been in enough therapy groups and doctors’ offices to know that the only reason people keep looking for answers in the face of crippling despair is because they believe something will help: drugs, doctors, relationships, therapy, or sometimes the sheer freedom of living at rock bottom. Nonetheless, I've seen the best results when I (and others) put faith not exclusively in doctors or drugs or therapies, which have their limits, but also in God. He is the reason I still believe in “something good” on the other side of my pain.
If you know someone in your church like me who is suffering, come alongside her. Pray for her. Avoid cheap platitudes like “have faith” and instead offer practical support by checking in on a regular basis to let her know she’s not alone, or by asking about her treatment, which is a way of acknowledging that the illness is real.
Resilience.
Millennials are on more antidepressants than any other generation. According to the CDC, more than 6 percent of 18-to 39-year-olds have been prescribed antidepressants. My generation might as well define ourselves as “behind” in our careers (40 percent of unemployed people are milennials), salaries, and personal lives (marrying late and moving back in with our parents). No wonder we’re depressed. On top of that, the hours we spend in psychiatrists’ or counselors’ offices dealing with symptoms of a disorder (or the side effects of medication) often feel like “lost” time. While dealing with my mental health problems, I have burned through a lot of time and money as well as emotional and relationship capital—all resources that I feel could have been spent better elsewhere. I find it reassuring to know that Christianity offers a promise of restoration greater than anything lost (Joel 2:25; Job 42:10–17). In the Bible, people often fall down, their lives fall apart, and yet God raises them up again.
With that in mind, if you encounter someone in your church who is struggling with suicidal ideation or any form of hopelessness, first affirm their pain, then offer them the grace of optimism.
The "seasonal" perspective.
“For now” is the mantra my therapist gave me to get through depressive episodes and hard days. Ecclesiastes 3 provides a similar mantra: “To everything there is a season.” Mental health, too, is composed of seasons. I am currently in a season for antidepressants, and although it may be cyclical, I hope it will eventually end. For most people, circumstances change, the brain’s reactions change accordingly, and the appropriate therapy also changes in sync with the situation. With mental health challenges, maintaining a long-range perspective is key to survival. The hardest, most important thing to do is simply to persevere.
If someone near you is facing a discrete mental health episode or a lifelong challenge, encourage her to name the season she’s in, remind her that seasons often change, and journey with her as she takes it one day at a time.
“I don't think I'm fixed,” Lovato shared in the MTV documentary about her “recovery” in a residential treatment facility. “People think that you're like a car in a body shop. You go in, they fix you, and you're out. It takes constant fixing."
Much like spiritual health, mental health is an ongoing need for every human being. Although those of us who struggle are each responsible for ourselves, we also rely on the powerful support of our community to ensure that we get the care we need. It starts with awareness within each local church. Just as an increasing number of secular figures have spoken up publicly, Christians should step forward to be, as Lovato put it, “proof that you can live a normal and empowered life with mental illness.”
The Bible is filled with exhortations to care for the most vulnerable among us—those who cry out for mercy and feel they have nowhere to turn. Those of us who face mental health crises are among the most vulnerable. We need your recognition. We need your prayers. We need your presence. And we need to be part of the church community, especially as we struggle to find extra grace.
The idea that one’s sex is a feeling, not a fact, has permeated our culture and is leaving casualties in its wake. Gender dysphoria should be treated with psychotherapy, not surgery.
For forty years as the University Distinguished Service Professor of Psychiatry at Johns Hopkins Medical School—twenty-six of which were also spent as Psychiatrist in Chief of Johns Hopkins Hospital—I’ve been studying people who claim to be transgender. Over that time, I’ve watched the phenomenon change and expand in remarkable ways.
A rare issue of a few men—both homosexual and heterosexual men, including some who sought sex-change surgery because they were erotically aroused by the thought or image of themselves as women—has spread to include women as well as men. Even young boys and girls have begun to present themselves as of the opposite sex. Over the last ten or fifteen years, this phenomenon has increased in prevalence, seemingly exponentially. Now, almost everyone has heard of or met such a person.
Publicity, especially from early examples such as “Christine” Jorgenson, “Jan” Morris, and “Renee” Richards, has promoted the idea that one’s biological sex is a choice, leading to widespread cultural acceptance of the concept. And, that idea, quickly accepted in the 1980s, has since run through the American public like a revelation or “meme” affecting much of our thought about sex.
The champions of this meme, encouraged by their alliance with the broader LGBT movement, claim that whether you are a man or a woman, a boy or a girl, is more of a disposition or feeling about yourself than a fact of nature. And, much like any other feeling, it can change at any time, and for all sorts of reasons. Therefore, no one could predict who would swap this fact of their makeup, nor could one justifiably criticize such a decision.
At Johns Hopkins, after pioneering sex-change surgery, we demonstrated that the practice brought no important benefits. As a result, we stopped offering that form of treatment in the 1970s. Our efforts, though, had little influence on the emergence of this new idea about sex, or upon the expansion of the number of “transgendered” among young and old.
Olympic Athlete Turned "Pin-Up" Girl
This history may clarify some aspects of the latest high-profile transgender claimant. Bruce Jenner, the 1976 Olympic decathlon champion, is turning away from his titular identity as one of the “world’s greatest male athletes.” Jenner announced recently that he “identifies as a woman” and, with medical and surgical help, is busy reconstructing his physique.
I have not met or examined Jenner, but his behavior resembles that of some of the transgender males we have studied over the years. These men wanted to display themselves in sexy ways, wearing provocative female garb. More often than not, while claiming to be a woman in a man’s body, they declared themselves to be “lesbians” (attracted to other women). The photograph of the posed, corseted, breast-boosted Bruce Jenner (a man in his mid-sixties, but flaunting himself as if a “pin-up” girl in her twenties or thirties) on the cover of Vanity Fair suggests that he may fit the behavioral mold that Ray Blanchard has dubbed an expression of “autogynephilia”—from gynephilia (attracted to women) and auto (in the form of oneself).
The Emperor’s New Clothes
But the meme—that your sex is a feeling, not a biological fact, and can change at any time—marches on through our society. In a way, it’s reminiscent of the Hans Christian Andersen tale, The Emperor’s New Clothes. In that tale, the Emperor, believing that he wore an outfit of special beauty imperceptible to the rude or uncultured, paraded naked through his town to the huzzahs of courtiers and citizens anxious about their reputations. Many onlookers to the contemporary transgender parade, knowing that a disfavored opinion is worse than bad taste today, similarly fear to identify it as a misapprehension.
I am ever trying to be the boy among the bystanders who points to what’s real. I do so not only because truth matters, but also because overlooked amid the hoopla—enhanced now by Bruce Jenner’s celebrity and Annie Leibovitz’s photography—stand many victims. Think, for example, of the parents whom no one—not doctors, schools, nor even churches—will help to rescue their children from these strange notions of being transgendered and the problematic lives these notions herald. These youngsters now far outnumber the Bruce Jenner type of transgender. Although they may be encouraged by his public reception, these children generally come to their ideas about their sex not through erotic interests but through a variety of youthful psychosocial conflicts and concerns.
First, though, let us address the basic assumption of the contemporary parade: the idea that exchange of one’s sex is possible. It, like the storied Emperor, is starkly, nakedly false. Transgendered men do not become women, nor do transgendered women become men. All (including Bruce Jenner) become feminized men or masculinized women, counterfeits or impersonators of the sex with which they “identify.” In that lies their problematic future.
When “the tumult and shouting dies,” it proves not easy nor wise to live in a counterfeit sexual garb. The most thorough follow-up of sex-reassigned people—extending over thirty years and conducted in Sweden, where the culture is strongly supportive of the transgendered—documents their lifelong mental unrest. Ten to fifteen years after surgical reassignment, the suicide rate of those who had undergone sex-reassignment surgery rose to twenty times that of comparable peers.
How to Treat Gender Dysphoria
So how should we make sense of this matter today? As with any mental phenomenon, what’s crucial is noting its fundamental characteristic and then identifying the many ways in which that characteristic can manifest itself.
The central issue with all transgender subjects is one of assumption—the assumption that one’s sexual nature is misaligned with one’s biological sex. This problematic assumption comes about in several different ways, and these distinctions in its generation determine how to manage and treat it.
Based on the photographic evidence one might guess Bruce Jenner falls into the group of men who come to their disordered assumption through being sexually aroused by the image of themselves as women. He could have been treated for this misaligned arousal with psychotherapy and medication. Instead, he found his way to surgeons who worked him over as he wished. Others have already commented on his stereotypic caricature of women as decorative “babes” (“I look forward to wearing nail polish until it chips off,” he said to Diane Sawyer)—a view that understandably infuriates feminists—and his odd sense that only feelings, not facts, matter here.
For his sake, however, I do hope that he receives regular, attentive follow-up care, as his psychological serenity in the future is doubtful. Future men with similar feelings and intentions should be treated for those feelings rather than being encouraged to undergo bodily changes. Group therapies are now available for them.
Most young boys and girls who come seeking sex-reassignment are utterly different from Jenner. They have no erotic interest driving their quest. Rather, they come with psychosocial issues—conflicts over the prospects, expectations, and roles that they sense are attached to their given sex—and presume that sex-reassignment will ease or resolve them.
The grim fact is that most of these youngsters do not find therapists willing to assess and guide them in ways that permit them to work out their conflicts and correct their assumptions. Rather, they and their families find only “gender counselors” who encourage them in their sexual misassumptions.
Those with Gender Dysphoria Need Evidence-Based Care
There are several reasons for this absence of coherence in our mental health system. Important among them is the fact that both the state and federal governments are actively seeking to block any treatments that can be construed as challenging the assumptions and choices of transgendered youngsters. “As part of our dedication to protecting America’s youth, this administration supports efforts to ban the use of conversion therapy for minors,” said Valerie Jarrett, a senior advisor to President Obama.
In two states, a doctor who would look into the psychological history of a transgendered boy or girl in search of a resolvable conflict could lose his or her license to practice medicine. By contrast, such a physician would not be penalized if he or she started such a patient on hormones that would block puberty and might stunt growth.
What is needed now is public clamor for coherent science—biological and therapeutic science—examining the real effects of these efforts to “support” transgendering. Although much is made of a rare “intersex” individual, no evidence supports the claim that people such as Bruce Jenner have a biological source for their transgender assumptions. Plenty of evidence demonstrates that with him and most others, transgendering is a psychological rather than a biological matter.
In fact, gender dysphoria—the official psychiatric term for feeling oneself to be of the opposite sex—belongs in the family of similarly disordered assumptions about the body, such as anorexia nervosa and body dysmorphic disorder. Its treatment should not be directed at the body as with surgery and hormones any more than one treats obesity-fearing anorexic patients with liposuction. The treatment should strive to correct the false, problematic nature of the assumption and to resolve the psychosocial conflicts provoking it. With youngsters, this is best done in family therapy.
The larger issue is the meme itself. The idea that one’s sex is fluid and a matter open to choice runs unquestioned through our culture and is reflected everywhere in the media, the theater, the classroom, and in many medical clinics. It has taken on cult-like features: its own special lingo, internet chat rooms providing slick answers to new recruits, and clubs for easy access to dresses and styles supporting the sex change. It is doing much damage to families, adolescents, and children and should be confronted as an opinion without biological foundation wherever it emerges.
But gird your loins if you would confront this matter. Hell hath no fury like a vested interest masquerading as a moral principle.
Paul McHugh, MD, is University Distinguished Service Professor of Psychiatry at Johns Hopkins Medical School and the former psychiatrist in chief at Johns Hopkins Hospital. He is the author of The Mind Has Mountains: Reflections on Society and Psychiatry.
When I was 15 years old, my mother picked me up at school to take me to a dental appointment. In the car, I could tell immediately that she wasn't functioning normally—she was headed for another "episode." She drove nervously, struggling to recognize her surroundings. She was silent except when I forced conversation, and when she did speak, her speech was slow and seemed to require deliberation.
It was as if half of her had already shrunk into some unknown place, and the other half was not sure whether to follow or to maintain her grip on the reality of her daughter and a trip to the dentist.
I asked Mom if she had taken her medication that day. Her answer was not straightforward, but it was clear that she was not fully medicated and stable. So with one part of my brain, I prayed for a safe trip to the dentist. With another part, I employed a technique used by many people who feel powerless in the face of an unnamed enemy: I acted as if nothing was wrong.
At the dentist's office, when my name was called, I left my mother in the waiting room and went back for my appointment. After half an hour or so with the dentist, I returned to my mom, who didn't look at me.
"Mom, it's time to go," I said. "I'm finished." I received no response of any kind. Suddenly I realized my instincts had been right: something indeed was wrong with Mom … again. And it was up to me to help her.
I touched her arm and gently tried to shake her back to awareness, with no results. She was rigidly catatonic, immovable, staring into space and clutching her purse in her lap with clenched hands—in a waiting room full of strangers.
After a couple of quiet attempts to rouse her, I began to attract attention. People stared at me as I tried to get her to respond. When she wouldn't move, I realized I needed to call my dad at work for help.
As everyone in the room continued to stare, I walked to the reception desk and asked the woman behind the counter—who was also staring—if I could use the phone.
"No, there's a pay phone around the corner," she said. When I explained that I needed to call my dad for help, I didn't have change for the phone, and it would be a local call, she still refused. So I went back to my mom and wrestled with her rigid arms, pulling them aside enough to get into her purse to find a quarter for the phone. I went back to the receptionist to ask if she could keep an eye on my mom while I went to use the pay phone. She shrunk back in horror: "Is she dangerous?"
After assuring the receptionist that my motionless mother was not about to attack her, I called my dad and then returned to sit next to my mom till he got there. The receptionist and the people in the waiting room took turns staring at my mom, glancing at me, and studying the floor. No one asked if I needed help.
In the years since, that incident has become for me a symbol. The way people in that waiting room responded to my family's public crisis is the way I've seen people—including those in the church—respond to serious mental illness. They didn't know what to do for my mom or anyone associated with her. So they did nothing.
Though I didn't know it at the time, my mother has schizophrenia. As often happens with schizophrenics, she had not been faithfully taking her anti-psychotic drugs and had lost touch with reality. Dad and I took her to the hospital for another of her psychiatric stays and restabilization on medication.
I have been doing a lot of thinking about session length lately. Over the past several years I have followed the trend of decreasing my session length to 45 minutes. I remember when sessions were standardized at 50 minutes when I started practicing 36 years ago. The idea was to see people for 50 minutes then have a 10 minute break between sessions, which worked pretty well for most people. Intakes were a little difficult to fit in that time for most people and often needed a longer time period. The biggest challenge was couples. Trying to fit a session with a couple into 50 minutes was always difficult and fitting them into 45 minutes, which is now the standard time that third party reimbursers ususally pay for, is even harder.
So with that in mind I thought I would adjust session length to 75 minutes to 90 minutes. Seventy-five minutes seems to work much better with most of the people I would with including couples and individuals and we don't seem rushed. Then I have 15 minutes between sessions if needed. People seem to treat time differently. Previously most of my clients came for weekly sessions but now they tend to come biweekly or longer, which actually works better for most people and especially couples giving them time to work on issues between sessions.
From a financial perspective it is more economical for clients to come less frequently and be seen longer at each session since I charge the same for 75 minute to 90 minute sessions as I used to charge for 45 minute sessions. I suppose I could charge more but I would rather take my time with each couple or individual and pass the cost savings on to them. For them it is like they get two sessions for the price of one each time and I get the luxury of a longer amount of their time when I have them, which is especially helpful since it is often difficult for clients and espeically couples to find time to be a couple let alone come for counseling.
I have also noticed the relaxed pace helps both me and my clients relax as well. I am not as sensitive to watching the time and being careful not to cross into the next session. This makes sessions seem rushed and often results in items getting moved to the next session, which due to client's time constraints may not occur with the frequence it once did.
This process may not work for all counselors but I find it effective for me and the folks I work with.
The leading Christian scholar on gender dysphoria defines the terms—and gives the church a way forward.
Mark Yarhouse / posted June 8, 2015
Image: Tom Maday
I still recall one of my first meetings with Sara. Sara is a Christian who was born male and named Sawyer by her parents. As an adult, Sawyer transitioned to female.
Sara would say transitioning—adopting a cross-gender identity—took 25 years. It began with facing the conflict she experienced between her biology and anatomy as male, and her inward experience as female. While still Sawyer, she would grow her hair out, wear light makeup, and dress in feminine attire from time to time. She also met with what seemed like countless mental-health professionals as well as several pastors. For Sawyer, now Sara, transitioning eventually meant using hormones and undergoing sex reassignment surgery.
Sara would say she knew at a young age—around 5—that she was really a girl. Her parents didn’t know what to do. They hoped their son was just different from most other boys. Then they hoped it was a phase Sawyer would get through. Later, two pastors told them that their son’s gender identity conflicts were a sign of willful disobedience. They tried to discipline their son, to no avail.
Sara opened our first meeting by saying, “I may have sinned in the decisions I made; I’m not sure I did the right thing. At the time, I felt excruciating distress. I thought I would take my life. What would you have me do?” The exchange was disarming.
I have worked with people like Sara for more than 16 years. Although most of my published research and clinical practice is in the area of sexual identity, I regularly receive referrals to meet with people who experience conflicts like Sara’s. The research institute I direct, housed at Regent University in Virginia, published the first study of its kind on transgender Christians a few years ago. My experiences counseling children, adolescents, and adults have all compelled me to further study gender dysphoria.
From this research and counseling background, I hope to offer the Christian community a distinctly Christian response to gender dysphoria.
Defining the Terms
First, let’s define our terms. “Gender identity” is simply how people experience themselves as male or female, including how masculine or feminine they feel. “Gender dysphoria” refers to deep and abiding discomfort over the incongruence between one’s biological sex and one’s psychological and emotional experience of gender. Sara would say she lived much of her life as a woman trapped inside a man’s body. When a person reports gender identity concerns that cause significant distress, he or she may meet criteria for a gender dysphoria diagnosis.
The previous version of the American Psychiatric Association’s diagnostic manual included the diagnosis “gender identity disorder.” It highlighted cross-gender identity as the point of concern. The newest version refers instead to “gender dysphoria,” moving the discussion away from identity and toward the experience of distress. A lack of congruence between one’s biological sex and gender identity exists on a continuum, so when diagnosing gender dysphoria, mental-health professionals look at the amount of distress as well as the amount of impairment at work or in social settings.
Editor's Note: What's In a Pronoun
A brief word about the pronouns we use to identify the people in this article and "Loving My Sister-Brother."
As the experiences of transgender persons have come to light over the past several years, mainstream media have created guidelines for reporting on them. Following general journalistic practice, we at CT follow a simple rule: Use the pronoun that the person uses. For example, we refer to Sara—the person at the beginning of this essay—as a "she," because Sara identifies as one.
Yet for the first-person essay from Margaret Philbrick, we deliberated. Calling Philbrick's sibling a "he" risked insensitivity. Yet using "she" didn't accurately convey Philbrick's own conflicted experience. In the end, we kept the male pronoun, to underscore the tension the family faces in navigating this life change. Carly Lehwald, Philbrick's sibling, has given us permission to use the male pronoun for this particular story.
-The Editors
It is hard to know exactly how many people experience gender dysphoria. Most of the research has been on “transsexuality.” The term refers to a person like Sara who wishes to or has identified with the opposite sex, often through hormonal treatment or surgery. The American Psychiatric Association estimates the number of transsexual adults as low as 0.005 to 0.014 percent of men and 0.002 to 0.003 percent of women. But these are likely underestimates, as they are based on the number of people who visit specialty clinics.
The highest prevalence estimates come from more recent surveys that include “transgender” as an option. “Transgender” is an umbrella term for the many ways people experience a mismatch between their gender identity and their biological sex. So not everyone who is transgender experiences significant gender dysphoria. Some people say their gender resides along a continuum in between male and female or is fluid. They do not tend to report as much distress. Prevalence here has ranged from 1 in 215 to 1 in 300.
This means that transgender people are much more common than those formally diagnosed with gender dysphoria, but not nearly as common as those who identity as gay or lesbian, which is 2 to 4 percent of the US population.
While on the topic of homosexuality, let me clarify that gender dysphoria and transgender issues are not about having sex or attraction to the same sex; they are about an experiential mismatch between one’s psychology and one’s biology. People often confuse the two, likely due to transgender being a part of the larger lesbian, gay, bisexual, and transgender (LGBT) discussion.
Psychologists and researchers don’t know what causes gender dysphoria. The most popular theory among those who publish on this topic is the brain-sex theory. It proposes that the brain maps toward male or female, which in nearly all cases corresponds with various biological indicators of sex: chromosomes, gonads, and sex hormones. In rare instances, the normal sex differentiation that occurs in utero occurs in one direction (differentiating toward male, for example), while the brain maps in the other direction (toward female). Several gaps remain in the research behind this theory, but it nonetheless compels many professionals.
Recently a mother came to me, worried about her 7-year-old son. “What can we do?” she asked. “Just last week a woman at the park said something. I couldn’t believe she had the nerve. I’m afraid the kids at school might do worse.”
The mother noted that her son’s voice inflection seemed more like a girl’s and that he pretended he had long hair. Over the past weekend, he had grabbed a towel and put it around his waist and said, “Look, Mom, I’m wearing a dress just like you!”
Gender dysphoria and transgender issues are not about having sex or attraction to the same sex; they are about an experiential mismatch between one’s psychology and one’s biology.
Whether and how to intervene when a child is acting in ways typical of the opposite sex is a controversial topic, to say the least. It’s important to remember that in about three of four of these cases, the gender identity conflict resolves on its own, lessening or ceasing entirely. However, about three-fourths of children who experience a lessening or resolution go on as adults to identify as gay, lesbian, or bisexual—a fact that psychologists don’t fully understand at this time.
What happens to children when their gender identity conflict continues into adulthood? Psychiatrist Richard Carroll proposes that they face four outcomes: (1) live in accordance with one’s biological sex and gender role; (2) engage in cross-gender behavior intermittently; (3) adopt a cross-gender role through sex reassignment surgery; or (4) unresolved (the clinician has lost contact with the person and doesn’t know what happened).
Sara pursued the third outcome. Bert pursued the second. He’s a biological male who for years has engaged in cross-gender behavior from time to time to “manage” his gender dysphoria. He wears feminine undergarments that no one apart from his wife knows about. He has grown his hair out and may wear light makeup, and this has been enough to manage his dysphoria.
Crystal pursued the first option. She has experienced gender dysphoria since childhood. It has ebbed and flowed throughout her life, but she’s able to cope with it. She presents as a woman and has been married to a man for 12 years. He is aware of her dysphoria.
Few studies have shown that therapy successfully helps an adult with gender dysphoria resolve with their biological sex. This may be one reason professionals generally support some cross-gender identification in therapy.
As someone with gender dysphoria considers different ways to cope, what might the Christian community distinctly offer them?
Three Lenses
To answer this question, let me first describe three cultural lenses through which people tend to “see” gender dysphoria.
Lens #1: Integrity. The integrity lens views sex and gender and, therefore, gender identity in terms of what theologian Robert Gagnon refers to as “the sacred integrity of maleness or femaleness stamped on one’s body.” Cross-gender identification is a concern because it threatens to dishonor the creational order of male and female. Specific biblical passages, such as Deuteronomy 22:5 or 23:1, bolster this view. Even if we concede that some of the Old Testament prohibitions were related to avoiding pagan practices, nonetheless, from beginning to end, Scripture reflects the importance of male-female complementarity set forth in creation (Gen. 2:21–24).
The theological foundation of the integrity lens raises the same kind of concerns about cross-gender identification as it raises about homosexuality. Same-sex sexual behavior is sin in part because it doesn’t “merge or join two persons into an integrated sexual whole,” writes Gagnon. “Essential maleness” and “essential femaleness” are not brought together as intended from creation. When extended to transsexuality and cross-gender identification, the theological concerns rest in what Gagnon calls the “denial of the integrity of one’s own sex and an overt attempt at marring the sacred image of maleness or femaleness formed by God.”
The integrity lens most clearly reflects the biblical witness about sex and gender. While it may be challenging to identify a “line” in thought, behavior, and manner that reflects cross-gender identification, people who see through the integrity lens are concerned that cross-gender identification moves against the integrity of one’s biological sex—an essential aspect of personhood.
It should be noted that some Christians do not put gender dysphoria in the same category as homosexuality. They may have reservations about more invasive procedures; however, they do put gender dysphoria or trying to manage dysphoria in the same class of behaviors that Scripture deems immoral.
Lens #2: Disability. This lens views gender dysphoria as a result of living in a fallen world, but not a direct result of moral choice. Whether we accept brain-sex theory or another account of the origins of the phenomenon, if the various aspects of sex and gender are not aligning, then it’s one more human experience that is “not the way it’s supposed to be,” to borrow a phrase from theologian Cornelius Plantinga Jr.
When we care for someone suffering from depression or anxiety, we do not discuss their emotional state as a moral choice. Rather, the person simply contends with a condition that comes in light of the Fall. The person may have choices to make in response to the condition, and those choices have moral and ethical dimensions. But the person is not culpable for having the condition as such. Here, the parallel to people with gender dysphoria should be clear.
Those who use this lens seek to learn as much as they can from two key sources: special revelation (scriptural teachings on sex and gender) and general revelation (research on causes, prevention, and intervention, as well the lives of persons navigating gender dysphoria). This lens leads to the question: How should we respond to a condition with reference to the goodness of Creation, the reality of the Fall, and the hope of restoration?
Those drawn to the disability lens may value the sacredness of male and female differences; this is implied in calling gender dysphoria a disability. But the disability lens also makes room for supportive care and interventions that allow for cross-gender identification in a way the integrity lens does not.
Lens #3: Diversity. This lens sees the reality of transgender persons as something to be celebrated, honored, or revered. Our society is rapidly moving in this direction. Those drawn to this lens cite historical examples in which departures from a clear male-or-female presentation have been held in high esteem, such as the Fa’afafine of Samoan Polynesian culture.
Whereas the biological distinction between male and female is considered unchangeable, some wish to recast sex as just as socially constructed as gender. To evangelicals, those who want to deconstruct sex and gender norms represent a much more radical alternative to either the integrity or disability lens.
To be sure, not everyone drawn to the diversity lens wants to deconstruct sex and gender. What is perhaps most compelling about this lens is that it answers questions about identity—“Who am I?”—and community—“Of which community am I a part?” It answers the desire for persons with gender dysphoria to be accepted and to find purpose in their lives.
A Distinctly Christian Resource
I believe there are strengths in all three lenses. Because I am a psychologist who makes diagnoses and provides treatment to people experiencing gender dysphoria, I see value in a disability lens that sees gender dysphoria as a reflection of a fallen world in which the condition itself is not a moral choice. This helps me see the person facing gender identity confusion with empathy and compassion. I try to help the person manage his or her gender dysphoria.
When I consider how best to counsel my clients to manage their gender dysphoria, I add the caveat: in the least invasive way possible.
Even as Christians affirm the disability lens, we should also let the integrity lens inform our pastoral care. That lens represents a genuine concern for the integrity of sex and gender, and the ways in which maleness and femaleness help us understand the nature of the church and even the gospel.
Yet we should reject the teaching that gender identity conflicts are the result of willful disobedience or sinful choice. The church can be sensitive as questions arise about how best to manage gender dysphoria in light of the integrity lens. And we can recognize that we live in a specific cultural context, and that many gender roles vary from culture to culture. When I consider how best to counsel my clients to manage their gender dysphoria, however, I add the caveat: in the least invasive way possible.
Christians can also acknowledge how the diversity lens affirms the person by providing an identity not addressed by the other two lenses. The diversity lens emphasizes the importance of belonging. We must remember that the transgender and broader LGBT community are attractive because they answer the bedrock question, “Where do I belong?” Most churches want to be a community where people suffering from any “dysphoria” will feel they belong, for the church is, after all, a community of broken people saved by grace.
A few years ago, my research team at the Institute for the Study of Sexual Identity conducted the first study of its kind on transgender Christians. We collected information on 32 biological males who to varying degrees had transitioned to or presented as women. We asked many questions about issues they faced in their home, workplace, and church, such as, “What kind of support would you have liked from the church?” One person answered, “Someone to cry with me rather than just denounce me. Hey, it is scary to see God not rescue someone from cancer or schizophrenia or [gender dysphoria]...but learn to allow your compassion to overcome your fear and repulsion.”
When it comes to support, many evangelical communities may be tempted to respond to transgender persons by shouting “Integrity!” The integrity lens is important, but simply urging persons with gender dysphoria to act in accordance with their biological sex and ignore their extreme discomfort won’t constitute pastoral care or a meaningful cultural witness.
The disability lens may lead us to shout, “Compassion!” and the diversity lens may lead us to shout “Celebrate!” But both of these lenses suggest that the creational goodness of maleness and femaleness can be discarded—or that no meaning is to be found in the marks of our suffering.
Most centrally, the Christian community is a witness to the message of redemption. We are witnesses to redemption through Jesus’ presence in our lives. Redemption is not found by measuring how well a person’s gender identity aligns with their biological sex, but by drawing them to the person and work of Jesus Christ, and to the power of the Holy Spirit to transform us into his image.
Let’s say Sara walks into your church. She looks like a man dressed as a woman. One question she will be asking is, “Am I welcome here?”
As Christians speak to this redemption, we will be tempted to join in the culture wars about sex and gender that fall closely on the heels of the wars about sexual behavior and marriage. But in most cases, the church is called to rise above those wars and present a witness to redemption.
Let’s say Sara walks into your church. She looks like a man dressed as a woman. One question she will be asking is, “Am I welcome here?” In the spirit of a redemptive witness, I hope to communicate to her through my actions: “Yes, you are in the right place. We want you here.”
If I am drawn to a conversation or relationship with her, I hope to approach her not as a project, but as a person seeking real and sustained relationship, which is characterized by empathy as well as encouragement to walk faithfully with Christ. But I should not try to “fix” her, because unless I’m her professional therapist, I’m not privy to the best way to resolve her gender dysphoria. Rather, Christians are to foster the kinds of relationships that will help us know and love and obey Jesus better than we did yesterday. That is redemption.
If Sara shares her name with me, as a clinician and Christian, I use it. I do not use this moment to shout “Integrity!” by using her male name or pronoun, which clearly goes against that person’s wishes. It is an act of respect, even if we disagree, to let the person determine what they want to be called. If we can’t grant them that, it’s going to be next to impossible to establish any sort of relationship with them.
The exception is that, as a counselor, I defer to a parent’s preference for their teenager’s name and gender pronoun. Even here I talk with the parent about the benefits and drawbacks of what they want and what their teenager wants if the goal is to establish a sustained, meaningful relationship with their child.
Also, we can avoid gossip about Sara and her family. Gossip fuels the shame that drives people away from the church; gossip prevents whole families from receiving support.
Chapters in Redemption
In some church structures, the person’s spiritual life is under the care of those tasked with leading a local congregation. In this case, we have to trust church leadership to do the hard work of shepherding everyone who accepts Christ as Lord and Savior. We trust, too, that God is working in the lives of our leaders to guide them in wisdom and discernment. We trust that meaningful conversations are taking place, and we can add our prayers for any follower of Christ.
In other church settings, it might be us as laypeople who are called into a redemptive relationship with the transgender person. After all, Christians are to facilitate communities in which we are all challenged to grow as disciples of Christ. We can be sensitive, though, not to treat as synonymous management of gender dysphoria and faithfulness. Some may live a gender identity that reflects their biological sex, depending on their discomfort. Others may benefit from space to find ways to identify with aspects of the opposite sex, as a way to manage extreme discomfort. And of course, no matter the level of discomfort someone with gender dysphoria experiences (or the degree to which someone identifies with the opposite sex), the church will always encourage a personal relationship with Christ and faithfulness to grow in Christlikeness.
Certainly we can extend to a transgender person the grace and mercy we so readily count on in our own lives. We can remind ourselves that the book of redemption in a person's life has many chapters. You may be witness to an early chapter of this person's life or a later chapter. But Christians believe that God holds that person and each and every chapter in his hands, until that person arrives at their true end—when gender and soul are made well in the presence of God.
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