Gender and Trichotillomania, Part I

Gender plays a significant role in the prevalence and presentation of trichotillomania, but it’s truly difficult to cram everything about it into one blog post. To make things worse, all the research I am able to find deals with genetics, statistics and demographics, not with cultural and psychological depths hair involves. Trichotillomania has consistently shown a gender bias in nearly all studies, with a higher prevalence among women compared to men. Studies have reported a female-to-male ratio of approximately 3:1 or 4:1 in clinical samples, although we always have to keep in mind that not everyone who pulls recognizes it as a problem or seeks therapy. Some newer studies that take this into account show that trich isn’t as gender specific as we thought, only that women have more courage to seek treatment, while men tend to suffer in silence.

Why is this important, you may ask? Because symptoms have meaning. Our symptom choice isn’t accidental. Some people might pull their hair but not pick their skin, or vice versa. You may do both. Other people might have panic attacks or become depressed, while someone else will end up with high blood pressure and become moody and impatient. The choice – although, clearly, not conscious – isn’t accidental either. Even if you only pull your hair, it’s likely that there is some selectivity to your pulling. I’ve had clients who only pull their pubic hair or their facial hair, some clients who only pull on one side of their head or in a specific region. Understanding these specificities can open up a whole world for psychological exploration.

As it turns out, gender differences can be quite important too. On the one hand, hormonal fluctuations, genetic predisposition, and the way societal expectations manifest in grooming and self-esteem can help us understand what triggers a person, when to take cautions and how, etc. On the other hand, one’s relationship with their gender as it’s seen within their culture can be the key to understanding their hair pulling.

I this blog, I will (hopefully) show why it’s so important to consider gender and culture in relation to hair pulling. In absence of research, I will rely on my nerdiness, my penchant for knowing irrelevant trivia and on my clinical experience. I will briefly present examples from my work with two clients – one female, one male – with their consent. They’ve also chosen the names I’ll use to refer to them.

Hair, culture, and gender

Hair carries profound cultural significance across diverse societies and throughout history. It serves as a canvas for personal expression and identity, reflecting an individual's choices, values, and affiliations, although not always consciously so – and always in relation to their culture. Hairstyles, colors, and grooming practices can convey a wide range of messages, from embracing rebellion when a high school student paints her hair in hot pink or courage, when you struggle with hair pulling and then shave your head even though you know that three decades after Sinead O’Connor did it, it’s still frowned upon by the prudes. Other times, people express their conformity with social norms by having certain hairstyles, they wear their hair so to say: “I’m just like you”, “I’m not sticking out”.

Cultural traditions often intertwine with hair, providing it with deep-rooted symbolism. That’s how we know or feel what someone’s hair means. When we live or grow up in a culture, we silently soak up its symbolic system, so seeing someone’s hairstyle often doesn’t require translation. In various Native American tribes, long hair holds spiritual and cultural significance, representing a connection to heritage and tradition. Conversely, some cultures, such as Hinduism, incorporate hair-cutting rituals at temples as acts of devotion, while Sikhism places spiritual value on uncut hair, symbolizing religious commitment.

The connection between hair and social status has been noted and has been rather important throughout history. Different societies have associated specific hair attributes with prestige, femininity, and beauty. For example, long, flowing hair has been perceived as a symbol of femininity and physical allure in some cultures. Think of Botticelli’s Venus! In contrast, shaved heads or meticulously styled hair may have represented prestige or devotion to religious practices – think about Buddhist nuns, for example. Hiding one’s hair can also be a sign of modesty or devotion, which is why Christian nuns wear headcovers. Historically, women were required to veil their heads when receiving the Eucharist.

Across many religious and spiritual traditions, hair plays a symbolic role. Religious texts often mention the significance of hair, linking it to spiritual aspects of life. In Christianity, long hair on women has been regarded as a symbol of submission to divine authority (1 Corinthians 11:15), so if you’re into submitting to divine authority, you will grow your hair long; unless you’re a guy, that is.

Hair also plays a role in various life transitions and rites of passage. For instance, in numerous cultures, a baby's first haircut is a celebrated event marked by rituals and ceremonies. Likewise, the act of cutting one's hair following a significant life change or loss can symbolize renewal, a fresh start, or a break from the past.

The relationship between hair and gender, as well as sexuality, is intricate and varies across societies. Your hair can be an expression of your sexual identity just as easily. Specific hairstyles may be used as markers of masculinity or femininity. Additionally, the grooming and maintenance of body hair often align with gender norms and prevailing standards of attractiveness. How these norms evolve is an interesting story for another blog.

Hair has been a powerful tool for resistance and empowerment. It’s deeply political. In certain contexts, individuals or groups have used their hair as a form of defiance or assertion of identity, a statement. During the early stages of the ongoing civil rights movement in the United States, for instance, the Afro hairstyle was embraced as a symbol of black pride and resistance against societal norms. If you’re a person of color, today just as ever before, your hair can be a source of pride, your connection to ancestry and culture, but also a source of shame, and that solely depends on the specific circumstances of your upbringing, the values you’ve internalized and how you create your own identity.

Furthermore, hair trends and styles are deeply influenced by fashion and popular culture and, especially when it comes to women, it would be foolish to disregard these trends in therapy. Women bear the brunt of cultural impositions nearly everywhere. These impositions rarely function without causing stress, body image issues and a host of other problems. Why would hair be the exception? The hairstyles of celebrities and influencers can significantly shape what is considered fashionable at any given time, highlighting the dynamic and ever-evolving nature of hair's cultural significance.

Hair pulling as resistance

Let’s consider Rachel. Nomen est omen, as they used to say in SPQR. My client chose her name for this article after her grandmother who was a bit of a rebel. When she was little, her grandmother served as a cautionary tale her parents used, “be good or you’ll end up like granny Rachel”. Grandmother Rachel was divorced three times and she ended up living alone in the middle of nowhere in Nebraska. When Rachel the client was old enough to get  to know her grandmother, she saw a different woman – a “witch” who wasn’t afraid to be a “bad woman” – a bad girl, a bad wife, a bad Christian. In fact, Grandma Rachel was an independent woman and in those days, that wasn’t a pardonable sin. She was a strange woman, to quote my favorite poet:

lonely thing, twelve-fingered, out of mind.
A woman like that is not a woman, quite.
I have been her kind.

(Her Kind, Anne Sexton)

My client Rachel – unlike her grandmother – didn’t have an easy time rejecting oppressive social norms and she wasn’t her Grandma Rachel’s kind, although she badly wanted to be without even knowing it – consciously. Her hair pulling would later tell a different story.

When she was little, my client was told by her father that she has to lose weight because “no one likes a fat girl”. Her mother agreed, explaining that “fat women have to work harder for everything, because no one really likes them”. So my client lost weight and made sure to never be overweight again. In her thirties, when she came to work with me, she would still automatically count calories before every meal. She was a gymnast, although not a professional one, as being good but not too good was a good balance for a girl in her family. One time, when she was 12, she asked her parents if she could cut her hair short. A shorter hairstyle would be convenient for gymnastics, she thought. The response she got is that her kind of a girl needs to have long hair, and not just long, but also blonde and silky. Otherwise, she just might end up alone on an empty farm, like Grandma Rachel.

When Rachel the Client was 14, one afternoon, she was combing her hair and trying to put it in a tight bun before the mirror, and she was getting frustrated. She was trying hard to be fast and efficient. She was late for gymnastics, and she needed to take care of her hair fast. Instead, her silky and disobedient blonde hair kept slipping away and running her plans. Eventually, out of frustration, she took two or three hairs and angrily pulled them out. To her huge surprise, she felt enormous relief. All the tension she felt suddenly evaporated. She quickly finished doing her hair and left.

A month later, when her father wouldn’t let her go out with her friends, she was sitting in her room and suddenly recalled this event. She began playing with her hair and that was the day when she discovered hair pulling.

As she was telling me the story of her long and complex relationship with hair pulling in therapy, years later, Rachel kept coming back to those episodes from her early adolescence and one theme began emerging: how pulling her hair was her way to say “screw you” to her parents and, by proxy, to the entire small-town culture she came from. But it was an ambivalent “screw you”, not an open, brave, public one. Hair pulling allowed her to relieve herself of tension and stress caused by the life she didn’t quite want to live, and it allowed her to use her hair, that symbol of blonde, gentle, conservative femininity that she couldn’t identify with. It allowed her to rebel against it, but not renounce it, to sabotage it through a pleasurable symptom.

Understanding Rachel’s hair pulling as a rebellion against her father and the culture she grew up in, helped us steer therapy in another direction, one that proved to be very useful as it set the stage for truly important changes that would lead to less hair pulling. We began understanding what kind of life, what kind of hair, makeup and jobs would align with Rachel that wanted to cut her hair back in elementary school. She wrote essays about Rachel with Short Hair, she meditated on her life and then slowly began implementing some of its elements into her real life.

Here's an excerpt from one of her writing assignments: And that is how Rachel with Short Hair was born. Her parents told her, “You can’t cut your hair; you're a lady,” but she took her father’s trimmer and did it herself. When her parents saw what she had done, they were angry and told her she looked like a lesbian. She ran away from home, took a bus to her grandma’s place, and her grandma told her that men get angry because they’re helpless and that there’s nothing wrong with being a lesbian and that she could be a lesbian on her farm, or anything else that she wanted or needed to be. There, at her grandma’s farm, she learned how to garden, and she never had to pull her hair. It was just as she liked it, and if she needed to pull anything, she could pull weeds.

How many Rachels are there?

In over a decade of being a psychotherapist, this isn’t the first story of its kind I heard. It’s one of many. Rachel was kind enough to allow me to user parts of her story to illustrate a point: while pulling is obviously very hard on those who pull and it leaves a whole host of unwanted consequences, it can also be a tool that helps you rebel quietly what you should be rebelling against out loud.

As we grow up, we internalize social beauty ideals and values through a complex process of socialization, which involves various influences such as family, peers, media, and society at large. Caregivers often transmit their own beliefs and preferences regarding appearance, subtly (or not so subtly as was the case with Rachel) reinforcing certain standards. For instance, parents may praise a child for their physical appearance, making comments about their attractiveness. They might express disapproval or concern about non-conforming traits. These early experiences can lay the foundation for how we perceive our bodies and value our appearance. They become a part of who we are. They no longer feel like something that’s imposed on us because we impose them on ourselves. As Foucault once pointed out, the way power works in our time is insidious: you don’t need overt political oppression, it’s through upbringing that you learn to oppress yourself. Rachel didn’t need her parents to remind her to be a lady every day because their voices lived inside of her and felt like a part of her.

There are many Rachels out there, and not all of them are women. We are all Rachel in one way or another, no matter what our “symptom of choice” may be. In another blog, we’ll discuss how trichotillomania has to do with masculinity too – no one is spared, but no one has to be stuck in this dark psychological corner either. Breaking the rules is really hard and often leads to massive disruptions of our interpersonal relationships. But we can’t stay the same and suffer for others, we have a responsibility to ourselves to live authentic lives.