Gender and Trichotillomania, Part II
In the first part of this series, I discussed a female perspective: what hair may mean to some women and how that affects and even leads to hair pulling. In this blog, we’ll turn to beards and hair in males and discuss two cases where cultural and religious expectations affected treatment and contributed to the evolution of symptoms.
Beards have held a profound and enduring connection to the concept of masculinity throughout history, transcending cultural boundaries. For all the fascinating cultural differences, most cultures have regarded beards as a sign of masculinity, albeit not always the most refined masculinity. For example, for much of Roman history, ancient Roman elites frowned upon beards and considered them somewhat barbaric. It was not until the peak of the imperial age (2nd century AD), that emperor Hadrian became the first “bearded emperor”, and this was met with some disapproval, as it was considered too Greek and not as sophisticated. Nonetheless, it was seen as masculine. This linkage between masculinity and beards perhaps finds its roots in biology as much as it finds it in culture and societal perceptions. Biologically, facial hair growth, driven by testosterone, is a telltale sign of male sexual maturity and an obvious difference that allows easy differentiation between the genders in traditional societies. Having a beard is a tangible marker of transitioning from boyhood to manhood.
In different cultures and epochs, beards have been emblematic of various traits commonly attributed to masculinity, such as wisdom, courage, and virility. In ancient Greece, bearded men were revered as wise philosophers and esteemed leaders, while Viking culture celebrated long, well-groomed beards as symbols of strength and valor. Even in many Native American cultures, beards denoted maturity and commanded respect.
Beards have often been tied to authority and leadership. Historical depictions of leaders, kings, and warriors have frequently portrayed them with prominent facial hair. Google Italy’s Giuseppe Garibaldi, and you’re likely familiar with Abraham Lincoln. Today, bearded individuals can still exude an air of authority and command respect, their facial hair symbolizing not just personal style but also confidence and gravitas. In some instances, beards styled in a particular way can indicate belonging to a culture or a subculture, therefore being a significant indication of one’s personal identity as well.
It's worth noting, however, that the symbolism of beards can fluctuate across cultures and eras. In some societies, a preference for clean-shaven faces may dominate, rendering facial hair symbolism less potent, while the very ability to grow a beard may still hold significance. Furthermore, modern interpretations of beards have evolved; while they still signify traditional masculinity for some, others view them as a form of self-expression and fashion, transcending gender boundaries in some instances. Beards are now embraced by individuals of any gender, and their significance encompasses a wide spectrum of personal expressions and identities.
In this blog, I will give two specific examples where trichotillomania was related to masculinity and religious demands – in different ways and different cultural contexts, but where social constructions of gender played a significant part in the genesis and treatment of trichotillomania, indicating deeper psychological layers that deserve exploration in therapy.
Judaism
Like most old religions, Judaism is rather diverse. I will limit myself to a particular group of ultraconservative Jews because this is the context relevant for the clinical example I wish to discuss.
In Hassidic Jewish communities, the religious significance of long hair and beards among men is deeply embedded in tradition but also in the interpretation of Jewish religious texts. These standards for male hair and beards are viewed as profound expressions of devotion, modesty, and unwavering commitment to Jewish law. In other words, they are mandatory and not negotiable for Hassidic Jews.
One of the central foundations for the practice of growing long hair and beards is to be found in the Torah. Leviticus 19:27 specifically commands that the "corners of the beard" should not be cut, which is widely understood to mean that Jewish men are to refrain from completely shaving their beards. This commandment is seen as an embodiment of the belief that individuals should honor and maintain the natural appearance that God has bestowed upon them.
Another commandment found in Leviticus 19:27 mentions not rounding off the "corners" or "edges" of one's head. Some Hassidic Jews interpret this commandment to mean that they should not trim or cut the hair at the temples, leading to the growth of side locks. These side locks are regarded as a distinctive sign, differentiating Jewish men, and underscoring their dedication to Jewish law. There is some freedom in terms of how these locks are styled.
Long hair and beards in Hassidic Jewish culture also symbolize modesty and humility. By allowing their facial hair and side locks to grow naturally and abstaining from excessive grooming or styling, Hassidic men emphasize humility before God. This practice serves as a constant reminder that their devotion and religious identity are of greater significance than outward appearances, truly a statement in the day and age we live in. These practices help create a distinct Jewish identity within the broader society, a sign of visible recognition of one’s values and belonging.
In some Hassidic traditions, the length and style of a man's beard can signify his marital status and religious role. Married men often grow long and full beards as a symbol of their dedication to their families and religious responsibilities. Conversely, unmarried men may have shorter beards or may not be required to grow one at all, reflecting their distinct religious and social status.
These customs and practices are not uniform across all Hassidic sects and communities, as variations in interpretation and individual preferences can influence their specific observance, something quite reasonable to expect in such an old and complex religion. Nonetheless, within the realm of Hassidic Judaism, long hair, beards, and side locks stand as enduring symbols of faith, modesty, and cultural identity.
The case
B. is 39 years old. He is married with three kids. He has been struggling with trichotillomania for about two decades. It’s a great source of shame, as he sees it as lack of control and his particular focus on pulling his beard causes him to feel intense guilt. At the time when he sought treatment, he began pulling his sidelocks too and this greatly disturbed him. Not only is he not in control of his behavior, but his trichotillomania is also now causing him to break important religious rules.
As we began exploring his trichotillomania, two contradictory facts emerged. First of all, he felt committed to his family and was fiercely protective of his wife and kids. At the same time, he was very clear about not being in love with his wife. His exact words were “I never learned how to love her”. Even though divorce was a possibility, he didn’t feel like that was a good move to make, primarily because of the ramifications that would have for his wife.
At the same time, he recounted a story of very strong infatuation with a girl that wasn’t Jewish, a kind of Petrarca-esque situation in which he was able to see her but knew that, because he will need to marry a Jewish girl, his infatuation will amount to nothing. When he told me this story, he immediately wrote it off as a juvenile adventure, but as our therapy progressed, he kept coming back to it. He first became aware of the story’s importance when he caught himself thinking about that girl during a particularly intense pulling episode where he pulled his beard and created a bold patch and barely prevented himself from moving on to pulling his hair too. Eventually, B. shared with me that every time he recounts the story or refers to it, he feels angrier about it. He felt angry at God for setting up the rules. He felt angry at himself for being so attached to those rules, for shaping his life according to them. At the same time, he felt he had no choice, since his belief in God and desire to follow those rules was sincere and profound.
From a practical standpoint, because he was unable to shave or cut his hair, that form of stimulus control was impossible to implement, and because this limitation came from a religious commandment, we had to work around it, although this was a minor issue that was resolved by finding other stimulus control techniques such as finger covers and gloves.
What we can see here is that B’s desire to pull his hair and beard had to do with his anger at God due to his lasting but impossible love and, on the other hand, lack of love in his marriage. While it may seem difficult to believe that one could hold on to infatuation after 20+ years, this wasn’t about infatuation but about a religious ban on pursuing it. For all we know, an adolescent infatuation would have been short lasting, and B knew as much. He was, however, angered that his religion required him to give up on his desire. Something that happened, in different forms, rather frequently and something that, surely, every religious person encounters from time to time. For B, each of these instances was adding more anger, anger that he didn’t know how to process and anger that he felt the need to hide, from himself primarily. All that anger stayed buried and resulted in repeated attacks on the symbol of his faith.
Our therapy focused on acceptance and forgiveness. This was an intense process that often transcended the psychological and went into more spiritual/religious and cultural spheres, but it was a process that resulted in nearly complete disappearance of hair pulling and a healthier relationship to anger and other negative emotions that B. came to see as spiritual challenges, rather than psychological issues. This shift allowed him to see his feelings as opportunities to grow, rather than a dysfunction that needs to be cured.
Upon the completion of our therapy, he and his wife decided to seek out marriage counseling. To the best of my knowledge, they both remained firm in their commitment to stay married but because of our work, he was able to open up to his wife only to discover that feelings (or lack of feelings) was mutual, although enormous respect and shared experiences and values were there and strong as ever. For both of them, this was a good starting point to build a happier, more fulfilling relationship.
Sicily
I have a house in Sicily and I spend most of my time here. One thing that caught my eye very quickly is that most men wear beards. Beards carry a significance that is deeply intertwined with history and culture in Sicily, going back all the way to ancient Greece. While this may seem like a long period of time for something to remain emotionally relevant, such traditions in Europe aren’t uncommon, especially in Italy where tradition is an explanation for many seemingly unusual and irrational things. For many Sicilian men, cultivating and maintaining a beard represents more than just a grooming choice; it reflects a multifaceted tapestry of tradition, identity, and individuality. It’s a form of communication, an expression of identity, position in society, but also a deeply personal choice. A beard in Sicily may be a tribute to the customs and values of their ancestors, a testament to their commitment to preserving and honoring their cultural heritage. In these beards, they see a link to the past and a way of carrying forward the traditions of their forefathers into the present.
In certain spheres of Sicilian society, beards may also convey authority, wisdom, and respect. A man with a beard can be perceived as someone with valuable life experience and knowledge, and this perception can extend into professional and social contexts. Moreover, in certain pockets of traditional Sicilian communities, beards may carry religious or superstitious connotations. Some believe that a beard can offer protection against spiritual or supernatural forces, while others may consider it a sign of piety and devotion.
The case
Pippo is 28 and he lives in Chicago. He moved there from Taormina, a small (although stunningly beautiful) town in Sicily, when he was 22. He has been pulling his beard since he was 18, when he began growing his beard. When we started working together, we began with habit reversal training, as this is usually a convenient place to start so that my clients experience a reduction in symptoms and to lay the groundwork for more meaningful, deeper psychological exploration. Pippo struggled to implement competing responses as his ADHD made creating new habits additionally difficult.
When I proposed to switch to stimulus control, he embraced gloves and finger covers and quite liked them. They were very effective and in a matter of weeks, most of the bold patches began growing back and slowly becoming invisible. However, he would pull his beard in public places where it wasn’t always possible to wear them and as his workload increased so did his pulling: stress was a trigger and there were fewer opportunities to use gloves and finger covers. In order to give us the upper hand over his very stubborn pulling, I suggested that he may want to consider shaving his beard. This would make pulling impossible and if he kept his face shaved for a few months, it would also give us time to develop better coping skills. I barely had time to finish my sentence before he decisively said no.
No, he was not going to shave his beard even if temporarily. He thought my suggestion was preposterous. Then he made a curious remark: just because I’m one of those men who don’t have beards, it doesn’t mean everyone else has to be. I invited him to elaborate on that more and he shared that, from his point of view (and his father’s and his grandfather’s point of view), not having a beard meant that a person doesn’t quite care about their masculinity. As strange as this sounds, at least when it comes to me, my client does have a point. Because I grew up in a completely different cultural environment, I wasn’t taught that being a man is somehow an identity I need to cultivate, I always felt it was enough to just know I am identified as one. For my client and his culture, being a man was something that needed to be articulated in a specific way. That meant – no shaving, even if it meant continuing to pull.
This obstacle proved to be quite important, as it allowed us to unlock some truly important layers of his trichotillomania: my client was pulling out important bits of his identity as a man!
Pippo shared things in “waves”, to use his own words. As he would gain more trust, he would give me more information. Opening up about his trichotillomania was difficult. Opening up about masculinity was also difficult. But then came another part: Pippo was gay. And in his very conservative, Catholic environment, this wasn’t the most amazing thing a person could be. His conflict wasn’t religious, as he and his family were only culturally Catholic. As he pointed out, until the early ‘90s, his family members routinely voted for the Italian Communist Party, so he was no friend of religion. Not being religious, doesn’t mean, however, that he avoided Catholicism. Insofar as one lives in Italy, one must contend with Christian values and this is obvious to me too, as a recent transplant. To put it bluntly, as Pippo put it to me, being gay meant that he was somehow less of a man. A case of internalized homophobia if there ever was one. But his internalized homophobia was what reinforced his attachment to beard, and his homosexuality is what harbored a lot of resentment to it. You see, it was incredibly important to appear as a “real man” and his beard played a pivotal role in this. At the same time, that beard symbolized the very system of values that made him feel as less of a man, so there was quite a lot of resentment directed at it as a symbol of his own oppression. Pulling his beard and carefully maintaining his beard was a wonderfully symbolic representation of a bigger, deeper struggle, between belonging to a community as a man and living his life aligned with his sexuality. His beard was masking that conflict, and I hope you can appreciate the layers of irony here.
