https://orcid.org/0000-0001-5358-5469
Abstract
Parallel to the advent of social media and the easy access to online pornographic content there is a sharp increase in adolescent females expressing gender dysphoria worldwide. This paper argues that treatment of gender dysphoria in female adolescents must include explicit exploration into their use and exchange of pornographic content, as well as possible online or offline contacts with adults. Possible avenues of how pornographic content may increase the shame and fear of becoming a woman include the acquisition of misogynistic sexual scripts based on false assumptions on sexuality including the normalization of the violation of females as pleasurable for them, peer influence among female friendship groups, the susceptibility of our medical systems to “mass hysteria” phenomena, easier access of adults with sexually abusive intentions to youth through social media, sexual abuse and victim blaming on females, as well as the influence of pornography on mentalization capacities. As the influence of pornography on gender dysphoria in girls is understudied, this paper provides questions for qualitative and quantitative research, case studies and history taking. Especially the lack of an adequate other during exposure may aggravate false assumptions on gender roles and gender inequality seen in mainstream pornography. Girls affected by autism might be at higher risk because of their reduced mentalization capacities. Working through experiences associated with pornographic content and sexually abusive experiences may correct false beliefs about gender inequality and therefore might alleviate gender dysphoria.
Introduction
The sex ratio of youth expressing gender dysphoria showed a recent inversion worldwide. Today, a markedly different population is seeking care: adolescent females. This phenomenon is paralleled by a sharp increase in numbers (Aitken et al., Citation2015; Bell, Citation2023; Kaltiala et al., Citation2020; Zucker, Citation2017).
Despite lacking consensus on the factors contributing to this new phenomenon, studies reveal a notable correlation between gender dysphoria and other neurodevelopmental and psychiatric disorders, along with adverse childhood experiences, including sexual abuse (Becerra-Culqui et al., Citation2018; Kaltiala, Heino, Marttunen, & Fröjd, Citation2023; Kaltiala-Heino, Sumia, Työläjärvi, & Lindberg, Citation2015; Kozlowska, Chudleigh, McClure, Maguire, & Ambler, Citation2020). Peer influence, particularly among girlsFootnote1 (Diaz & Bailey, Citation2023; Hutchinson, Midgen, & Spiliadis, Citation2020; Littman, Citation2018; Zucker, Citation2019), and susceptibility of the medical and therapeutic system to mass hysteria (Marchiano, Citation2021) has been suggested as potential factors.
Optimal therapeutic strategies for addressing youth gender dysphoria remain a subject of debate: some advocate for early gender identity affirmation, including medical intervention (Ashley, Citation2019; Coleman et al., Citation2022), while others emphasize the importance of a conservative approach addressing psychiatric comorbidities and exploring the developmental etiology of the dysphoria through psychotherapy (Ayad et al., Citation2022; Levine & Abbruzzese, Citation2023). Several countries have changed their first line treatment from affirmation to exploration due to lack of scientific evidence for the efficacy and safety of medical treatments. Finland (Council for Choices in Health Care in Finland (PALKO/COHERE Finland), Citation2020), Sweden (Socialstyrelsen - The National Board of Health and Welfare, Citation2022) and Great Britain (Cass, Citation2022) are among these countries.
The sharp increase in youth affected by gender dysphoria coincides with the proliferation of mobile internet access and social media, making pornographic content easily accessible for children as young as 8 years (Gassó & Bruch-Granados, Citation2021). Although no studies have yet directly linked exposure to pornography with gender dysphoria, research shows that such exposure can assume traumatic relevance for children and adolescents (D’Alberton & Scardovi, Citation2021). It can distort their sexual knowledge, and aggravate their perception of gender inequality toward severe misogyny, as it normalizes victimization and degradation of girls and women (Wright et al., Citation2022b). At the same time, social media, chat rooms or online games allow adults with abusive intentions to easily contact children and adolescents without the knowledge of their parents and caretakers.
Parents or caretakers are largely unaware of the pornographic content to which their children and adolescents are exposed (Wright et al., Citation2022a). To understand the potential impact of pornography on identity formation, gender role expectations, and feelings toward their body as it develops into adult female shape, it is vital to explicitly and routinely ask for the experiences with pornographic content or sexual contacts in history taking for therapeutic exploration. The aim is to assess potential traumatic relevance and to provide an adult perspective to assist the young patients in working through their feelings.
Gender dysphoria in girls
The recent inversion in the sex ratio of adolescents presenting with gender dysphoria from natal males to natal females has yet to be explained (Bell, Citation2023; Kaltiala et al., Citation2020; Zucker, Citation2017). Peer influence has been suggested in both sexes (Diaz & Bailey, Citation2023; Hutchinson et al., Citation2020; Littman, Citation2018; Zucker, Citation2019), with evidence suggesting that social contagion is more prevalent among girls than boys (Papadima, Citation2019). In her study on youth expressing puberty onset gender dysphoria, Littman (Citation2018) found predominantly natal females. Their rapid and sudden onset of dysphoria let her coin the term “Rapid onset gender dysphoria (RoGD)” for this population. Their dysphoria spread within friendship groups. Littman points out similar social contagion patterns in eating disorders as well as self-harming behavior.
Parallel to the increase in medically transitioning youth, there is a corresponding rise in individuals regretting their interventions (Levine & Abbruzzese, Citation2023). A recent comprehensive review of the medical records of youth (19.2 ± 5.3 years) from the US Military Healthcare System between 2009 and 2018 revealed that within 4 years 36% of natal females and 19% of natal males discontinued “gender affirming” hormones (Roberts, Klein, Adirim, Schvey, & Hisle-Gorman, Citation2022). Research into care pathways for gender questioning youth found that up to two thirds of patients did not receive recommended monitoring standards (Boyd, Hackett, & Bewley, Citation2022). The authors raised the “question about the phenomenon of overdiagnosis, overtreatment, or iatrogenic harm as found in other medical fields”. This concern is confirmed by many detransitioned individuals, again predominantly natal females (Littman, Citation2021).
Therefore, the health system may be part of the problem by prematurely drawing conclusions about an adolescent’s identification process. Health systems have been shown to be susceptible to the phenomenon of mass hysteria, where the fascination for seemingly new phenomena leads to new and misleading diagnoses that withstand proper scientific rigor for decades (Marchiano, Citation2021). Marchiano explores two such diagnoses, namely the hysteria diagnosis and anorexia, both affecting mainly female adolescents and young women. The hysteria diagnosis was propagated by the French psychiatrist and neurologist Jean-Martin Charcot at the end of the nineteenth century. He held regular weekly lectures in which he would exemplify hysteric symptoms on his female patients in what became dramatic spectacles. These lectures became very popular and were visited by the interested public (Showalter, Citation1997 cited in Marchiano, Citation2021). For anorexia, the population of women affected changed drastically after the popularization of the disorder in the 1970s (Watters, Citation2011 cited in Marchiano, Citation2021). Based on this, Marchiano explains the interplay of popular culture and symptoms expressed by patients. She argues that symptoms may gain “cultural currency through a complex and largely unconscious negotiation between the medical establishment, activists and advocates, media, and the patients themselves. Once these symptom templates have been codified and validated, they can be found by those unconsciously seeking to express wordless distress“. Marchiano proposes that the precocious "affirmation" of trans identity in adolescents by the therapeutic and medical system is a modern example of such a mass hysteria phenomenon. She concludes that „The medical and mental health fields must guard against becoming entranced by exotic new conditions such that, in our excitement, we unconsciously reinforce maladaptive behaviors“, thus stressing the responsibility of the mental health professionals to carefully examine themselves and their patients.
Apart from social contagion and mass hysteria phenomena, the rumination on gender can be used as a defense mechanism to avoid more profound questions about connection, aloneness, authenticity, loss and sexual abuse (D’Angelo, Citation2020). Sexual abuse has been shown to be high in girls presenting with gender dysphoria (Kozlowska et al., Citation2020). Although there are no studies to date that directly relate the exposure to pornography to the expression of gender dysphoria, the exposure to pornography has been related to the perception of gender equity, sexual permissiveness and the probability to become a victim of sexual abuse.
Becoming a woman with pornographic content available through social media
Research shows that the consumption and exchange of pornography can start in an age as young as 8 years and increases during adolescence (Gassó & Bruch-Granados, Citation2021). The pornographic content being shared is often neither innocent nor consensual: for instance, the German criminal statistics 2022 reported that nearly half (41,1%) of the illegal porngraphic content (depicting minors) were distributed by minors (Bundesministerium des Innern und für Heimat [Department of the Interior, Germany], Citation2023). Mainstream porn shows a distinct and misogynistic gender difference in the behavior of the proponents with males depicted as having more agency, and male orgasms are shown more often than female orgasms (Fritz & Paul, Citation2017). Most importantly, aggression being mostly directed at females is combined with female actors performing neutral emotions or sexual pleasure (Shor, Citation2019). These observations raise the question: how is the sharing of such content experienced by adolescent females transitioning into womanhood?
While sexually explicit content does not necessarily have negative effects on feelings about their body and feelings about sexuality, several studies have shown that this risk cannot be ignored. Consuming online porn was correlated with distorted sexual knowledge and aggravated assumptions of gender inequality (Donevan et al., Citation2022; Gassó & Bruch-Granados, Citation2021; Wright et al., Citation2022b). False sexual beliefs perpetuated by the exposure to pornography include: rough sex is common (e.g., sex involving gagging, spanking, and insults), more gentle sex is comparatively rare (e.g., sex involving kissing, hugging, and compliments), most women enjoy anal sex (Wright et al., Citation2022b, ).
Table 1. Consumption patterns of pornographic content and sexual knowledge.
For both sexes, porn consumption was correlated with sexual permissiveness (Huntington, Willoughby, & Rhoades, Citation2022; Lo & Wei, Citation2005). However, the behavioral choices of girls and boys differed with female adolescents showing higher rates of victimization and male adolescents showing higher rates of assaults when consuming more porn (Donevan et al., Citation2022; Rostad et al., Citation2019). Thus, female adolescents are living in a reality which is split into contrary parts: on the one hand they legally have equal rights, but on the other the exchange of pornographic content can aggravate misogynistic assumptions of gender inequality with girls/women being objectified, victimized and violated.
Sexual permissiveness extends beyond adolescent peer interactions: surveys have revealed adults exploiting social media platforms to contact minors with sexually abusive intentions (Greene-Colozzi, Winters, Blasko, & Jeglic, Citation2020; Nennstiel & Isenberg, Citation2021). In a representative survey on 1905 minors aged 8 to 18 adults were shown to have directly contacted minors through Instagram, WhatsApp, Snapchat, TikTok, Facebook and social media platforms including online games. Minors received requests for personal meetings, were asked to send pictures, were asked to put off clothes and turn on the camera, were sent nude pictures of the offender, and received threats of exposing their pictures if they didn’t comply (Nennstiel & Isenberg, Citation2021). The follow up survey in 2022 (Nennstiel & Isenberg, Citation2022) for a number of 2002 minors aged 8-17 revealed a consistent rise in sexual solicitation rates, especially among the youngest group of 8-10 year old children: the solicitations rates more than doubled for some types of solicitations with the lowest rise for the request to turn on the webcam from 7.9% to 11.7% of the children, representing a 48% rise, and the highest for the request of meeting in person from 8.8% to 20.4% of the children, representing a 132% rise (See also ). In a retrospective survey, 25% of the respondents reported having conversed with adults online when there were minors, with 65% of those experiencing sexual solicitation. Of all respondents, 23% reported long and intimate conversations with a pattern of sexual grooming with unknown adults. Of these, 38% met these adults in person and in more than half of the cases (68%) the adults achieved sexual intercourse with the minors (Greene-Colozzi et al., Citation2020).
Table 2. Grooming.
In summary, the consumption and exchange of pornography increases the risk of reinforcing misogynistic stereotypes of gender inequality, female victimization/abuse, and normalizing aggression toward females. Both male and female children and adolescents may internalize the idea that aggression toward females leads to sensory pleasure for all persons involved, including the females. For girls in the vulnerable and malleable period of adolescence and puberty, this risk may amplify internal sexism (Bozkur, Citation2020) () and intensify the pain, shame, and fear associated with becoming a woman. If internalized sexism is the underlying motivation for transitioning from female to male, then an “affirmation” of the wish to transition is not benign, but a collusion preventing healthy psychic development of the girl (Bell, Citation2023). Contesting the early psychoanalytic concept of “penis envy”, Karen Horney (Horney, Citation1926) described what she perceived as a “flight from womanhood” as a response to societal subjugation of women. This flight might be exacerbated today by the portrayal of aggression against women as pleasurable in pornographic content.
Table 3. Internalized sexism.
Abuse and abandonment in female adolescence
Puberty entails painful insecurities and the search for one’s own place in society. Female adolescents today are left alone with the painful discrepancy between the theoretical idea of gender equality and the harsh reality of sexual objectification targeted specifically at young females. For instance, in the German Ministry of Interior report from 2022, victims of sexual assault were female in 92.4% of the cases. Minors in puberty and young adults carry the highest burden in sexual assaults: while the age of victims ranged from children under 14 to adults more than 80 years old, about a quarter of the sexual assault victims (25,6%) were between 14 and 21 years old and more than half of the victims (56%) were within the age range 14-25 (Bundesministerium des Innern und für Heimat [Department of the Interior, Germany], Citation2023).
Female adolescents have been shown to receive little support when talking about sexual abuse. In the case of non-consensual exchange of intimate pictures, victim blaming from teachers and peers was observed (Pia, Witz, Böhm, Dekker, & Budde, Citation2023). Men have demonstrated higher rape myth acceptance and attributed more blame to to victims, particularly women violating traditional gender roles (Grubb & Turner, Citation2012). Young women have been shown to suppress their views and remain silent in heterosexual relationships to be considered a “good” partner while behaving outspoken was seen as a risk for their acceptance in their social environment (Samardzic, Barata, Morton, & Yen, Citation2023).
During puberty, adolescents often refrain from sharing intimate issues with parents or therapists. Parents have been shown to be largely unaware of the online consumption patterns and underestimate their exposure to pornography (Wright et al., Citation2022a). Higher social and economic status has not been shown to be a protecting factor. Instead, porn addiction in adolescents increased with household income and education status (Longe et al., Citation2007). As a result, girls are too often being left alone with processing their feelings related to the abuse of women in pornography and possible abusive experiences with peers or adults.
The necessity of an adequate other
In their contributions to the special issue „Internet Pornography: Psychoanalytic Reflections on its Effects upon Children, Adolescents and Young Adult’’ in The Psychoanalytic Study of the Child Lemma (Citation2021) and D’Alberton & Scardovi (Citation2021) among others stress that it is the lack of the responding other that leads to potential traumatic impact. By asking questions, discussing, marking and containing feelings adult care takers and therapists can help children and adolescents to work through their feelings and mitigate potential trauma. In particular what D’Alberton & Scardovi (Citation2021) call an investment into „the subject’s instinctual quality“, and Lemma (Citation2021) describes as mentalization capacity can help in processing overstimulation. Mentalization can be understood as the capacity to understand others and one’s own behaviors in terms of mental states (Fonagy & Allison, Citation2014); it entails the ability to reflect one’s own behavior from the perspective of the other, thus also recognizing that the other has its own mental states. By this, mentalization includes the endurance of ambivalence (Bateman & Fonagy, Citation2019), namely that oneself and the other may experience divergent mental states. However, when pornographic content is consumed, the other is not present in sexual communication. The habitual use of online pornography may thus “untrain, or impede, the development and exercise of the capacity to mentalize one’s own desire and the desire of the other” (Lemma, Citation2021).
As an example, if aggression toward women is shown as inciting pleasure in the violated women, both male and female spectators may lose the instinctual quality that violence first and foremost results in pain and fear, as well as flight or aggression. In male adolescents, the use of the internet can promote omnipotence and can lead to instrumentalizing others (Sugarman, Citation2021). For female adolescents, the connection of violence toward women and pleasure may lead to untrain or impede the capacity to mentalize their own fear, flight, or aggressive feelings; they may confuse the acted pleasure of the female porn performer with their own expectations of what pleasure can be for themselves.
Adolescents presenting with gender dysphoria not only show higher than normal prevalence of adverse childhood experiences such as sexual trauma, but also higher prevalence of autism (Becerra-Culqui et al., Citation2018; de Vries, Noens, Cohen-Kettenis, van Berckelaer-Onnes, & Doreleijers, Citation2010; Kaltiala-Heino et al., Citation2015; Levine & Abbruzzese, Citation2023; Littman, Citation2021). Mentalization is especially difficult for people in the autism spectrum (White, Hill, Happé, & Frith, Citation2009), a condition underdiagnosed in females (Lockwood Estrin, Milner, Spain, Happé, & Colvert, Citation2021). For this population, concretistic thinking, rigid perspectives and low endurance of ambivalence are typical. Since knowledge on autism cannot be expected from parents or untrained caretakers, it is therefore crucial for therapists to provide tools that enable autistic individuals to process stimuli from pornographic content.
Conclusion
Currently the etiology of youth gender dysphoria, particularly that emerging in adolescent or pre-adolescent natal females is poorly understood and there are likely to be multiple contributing biopsychosocial factors interacting in complex ways. Research is needed if the consumption of online pornography adds to the factors aggravating gender dysphoria in Girls. In the meantime this paper recommends health professionals to consider their patients’ engagement with pornographic content during exploration. This includes explicitly asking about sexual content exchanged in peer groups or with adults through chats, online games or other social media platforms. It includes asking if presents were accepted for showing themselves, as well as if offline contacts have occurred and what happened. Health professionals must then offer an adult perspective on the experiences of their patients. They should explicitly ask for their conception of gender roles and correct relevant aggravations of gender inequality, including the normalization of violation toward women as pleasurable and other forms of misogyny. A list of possible questions is provided in . These questions can be used in qualitative or quantitative research, in case studies as well as in history taking. Therapists should then explore the feelings of their patients regarding their own developing female body in relation to the pornographic content. By carefully working through these experiences, it may be possible to enhance mentalization capacity and alleviate the fear, shame, and pain associated with becoming a woman. It is only after exploring the influence of misogynistic pornographic content on the conception of self of the female patient, that the impact of this content on gender dysphoria can be assessed.
Acknowledgments
I’m thankful for Björn Nadrowski, Artemis Papert, and Leonore Tiefer and three anonymous reviewers for reading and commenting on the manuscript.
Disclosure statement
The author reports there are no competing interests to declare.
Additional information
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Notes
1 Throughout the paper, I will refer to “girls” in the sense of adolescent natal females, since the topic is their unease with their growing sexed body. However, “woman”, especially in porn, can also include transwomen, if they are read as female by the girls watching the porn.
References
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