Abstract
Body-focused repetitive behaviors are DSM-classified as obsessive-compulsive spectrum disorders, but sufferers are frequently treated as being to blame for making themselves “ugly.” The case of trichotillomania reveals the stigma incolved in “violating” beauty norms and the work people do to conceal both the effects and the cause of their deviance.
I don’t consider myself particularly feminine; I’m queer, nonbinary, and I try to present as femme-of-center androgynous (accomplished with as little work as possible). I don’t spend much time styling my hair (a few upward swipes of pomade on towel-dried hair will do), my skincare routine consists of a quick application of an SPF moisturizer, and I don’t wear foundation or concealer. But every morning, like clockwork, I painstakingly draw on black eyeliner with the tiniest wings, then glue on false eyelashes. What gives?
I have trichotillomania, a body-focused repetitive behavior (BFRB) currently classified in the Diagnostic and Statistical Manual (DSM-V) as an obsessive-compulsive spectrum disorder. Additional BFRBs include skin picking (sometimes called “excoriation” or “dermatillomania”), nail biting, cheek biting, and similar behaviors. Trichotillomania, or “trich” (pronounced “trick”) for short, is characterized by compulsively or repetitively pulling out hair anywhere on the body in a way that is distressing to the individual. My “pull areas” are the eyebrows, top eyelashes, and scalp, but people might pull from one or more areas of the body, including beard, arms, pubic area, or anywhere else hair grows. There’s no cure, and 20+ years of clinical trials and research across psychiatry, neuroimaging, genetics, and other fields have not been able to pin down a consistent cause. Current estimates suggest that approximately 1 in 50 people will experience trich in their lifetime. I frequently tell people that I am not the only person they know with trich, but I might be the only one who talks about it. Research shows that most “trichsters” (pronounced like “tricksters,” a nickname often used within online trich support communities) experience shame or embarrassment over the behavior and/or the areas where the effects of pulling are visible, and they spend a lot of time and money on concealment. In the past 18 months, I’ve spent nearly $1,400 having my eyebrows microbladed and retouched to avoid drawing them on daily. I stopped keeping track of how much I spend on false lashes.
I constantly worry others will notice my sparse eyebrows or eyelashes, that someone will learn about my trich and think less of me, and that my pulling will become my defining characteristic. In fact, while engaged in graduate research on trich, a senior faculty member told me to change topics so as to avoid becoming “known as the one with the hair thing.” I rarely share my own trich status with my students or colleagues when talking about this research, even though self-disclosure was pivotal in participant recruitment and rapport-building.
Trichsters have vastly different experiences dealing with our symptoms, and in 2015, I interviewed 33 people about how they navigate life with trich. Through analysis of my own experiences as well as those of my participants, I find that trichsters occupy the intersection of two co-constructive types of deviance: mental illness and violation of beauty norms. Trich is defined as a mental illness because it is seen as an intentional violation of beauty norms, and the violation of beauty norms is a visible manifestation of mental illness.
Intersecting Deviances
Hair restoration and replacement is a multi-billion-dollar industry worldwide, spanning cosmetics, medicine, and other health and wellness industries. People who use these products and services are often hoping to appear younger or hide hair loss—usually on the face or scalp—from aging, alopecia, chemotherapy, or burns, all of which are seen as socially acceptable reasons for hair loss (even if the hair loss itself is unacceptable). Some beauty practices are acknowledged as being a cause of hair loss, such as tight hairstyles (e.g., traction alopecia from cornrows or ballerina buns) or frequent use of chemical treatments (e.g., dyes, perms, or relaxers). However, trich has a more complicated meaning and cultural interpretation. The few examples in mainstream media portray trich as weird and deviant, and people who have it as sick and unattractive. While there is a spectrum of impact and visibility across trichsters, media portrayals usually include more severe cases characterized by large bald spots on the scalp (e.g., Law and Order: SVU, Life and Beth) or a character engaged in the act of pulling (e.g., Modern Family).
iStockPhoto.com // courtyardpix
Modern Eurocentric beauty norms dictate the requirements and limits of acceptable hair removal, as well as the “right” places for removal. For example, to align with dominant ideals of beauty and femininity, women are expected to remove the hair from their legs, armpits, and bikini line. Eyebrows can be shaped by plucking or waxing—this is considered “good” hair removal—while removing them entirely is “bad.” However, even the acceptability of eyebrow plucking is on a spectrum. Some hair removal for shaping purposes is okay or even encouraged. Overplucking (e.g., accidentally or intentionally making them “too” thin according to current trends) is considered undesirable, and intentionally removing some or all of the eyebrows to align with a trend or subculture might be considered strange in dominant society. Trichsters constantly navigate mixed messaging: Some hair removal is necessary, but we are doing it wrong, and because of the manner in which we do it, there is something wrong with us.
Hairdressers can be among the few people who know their clients struggle with trich.
iStockPhoto.com // Drazen Zigic
“Making Yourself Look Bad”
Several participants reported being bullied, made fun of, or otherwise questioned about their hair loss in a way that reveals the stigma of not having hair in those particular areas. However, they were generally unwilling to explain that they are the ones causing the hair loss. Lucy, a White woman, pulls her eyebrows and does not draw them in. She generally keeps her hair dyed blond in hopes that others will not notice her lack of eyebrows. She reflected on what it is like when someone does notice, like her co-worker: “This is how it always happens, they’ll just give me this look, like there’s this look and you can tell that they’re looking at your eyes. And then they ask, and I can always sense it, every time. And I know it’s gonna come. So he was looking at me, and I was like, ‘Oh god.’ And then he just was like, ‘You don’t have eyebrows?’ And I was just like, ‘[sigh] Nope.’ Like I don’t even know how to answer anymore, because I want to be super mean, but I can’t, because I’m embarrassed and stuff... and he was like, ‘Why?’ and I was like, ‘That’s really none of your business.’... It’s kinda like, ‘Ugh, thanks for reminding me that I’m different.’“ By asking Lucy why she does not have eyebrows, her co-worker implied that there must be a particular reason for the absence.
Logan, a White man, recalled that when his pulling was at its most severe, he had several bald spots on his head that he usually covered with a hat. He remembered the time his former boss first saw his bald spots: “We were on his boat, and my hat blew off... I’m sitting right in front of him, and he’s like, ‘Logan, what the fuck is wrong with your head, dude?’ And I was like, ‘I don’t know, I guess I’m stressed out and shit, my hair is just falling out.’“ Logan’s boss was more explicit than Lucy’s co-worker in pointing out the hair loss, but the implication is the same: Something out of the ordinary must have happened to cause it. Logan came up with an excuse that he believed to be both plausible and acceptable—having hair falling out due to stress removes the blame from him.
Most participants had similar cover stories for their hair loss, such as Mary, a White woman who explained, “I tried fake eyelashes and the glue got stuck to my eyelashes and pulled them out,” or Ken, a White man, who blamed the hair missing from the back of his hands on an old chemistry injury. My own excuse for my missing eyelashes as a teenager was, “I got into a fight with an eyelash curler.” Lea, a Black woman, explained why she refused to tell others that her hair loss comes from pulling: “I would think that they would think that I’m unstable.... It’s embarrassing, I don’t—you know what I mean? They would think less of me, they would think I’m a weirdo or a freak or some—that’s why I avoid telling people what the real situation is.”
These cover stories are meant to lessen the impact of our deviance by giving a more socially acceptable cause—accidents and illnesses happen, but pulling might be perceived as intentional. Anya, a biracial (White and Arab) woman, described the duality of the deviances trichsters embody: “So it’s almost like you have two sets of problems—one that you’re making yourself look bad, so there’s that, and two, the fact that you’re doing it to yourself. So I think there’s a certain—where people think, ‘Oh my god, what is wrong with her?’“ Anya’s explanation reveals that not only is the hair loss a violation of beauty norms, but the idea that a person is causing the hair loss themselves by pulling it out adds a dimension of blame.
“Why Don’t You Just Stop?”
The shame and embarrassment of having trich are reinforced by a question that is more of an accusation: “Why don’t you just stop?” Most of the trichsters I spoke to had heard this from friends, family, and even healthcare workers and therapists, and they all described the question as frustrating, harmful, and stigmatizing. Ultimately, asking a trichster why they can’t stop—or otherwise commanding them to stop—might be more harmful than the pulling itself.
The beauty work trichsters do has two dimensions—it is meant to hide both the cause and the effect of thinning, patchy, or bald pull areas.
iStockPhoto.com // aetb
Olivia, a White woman, began hearing this message from her parents when she was a child: “They were telling me to stop it, like I should be able to just stop doing it. Um, like it’s a moral thing or a choice rather than a compulsion.... I think both of them tried the shaming and the, ‘You shouldn’t be doing that, that’s stupid, why are you doing that, you’re making yourself ugly.’“ Trichsters internalize messages about beauty from all around us, giving us plenty of self-shame. As a child, Olivia did not have a way to respond, but Star, a Black woman, explained how she responds when her family shames her: “My family came into town for the holiday break, and they’ll ask, ‘How’s your pulling, are you still pulling?’ And the answer’s always yes. ‘Well, you should stop.’ So, it’s like that, and, ‘If you just stop pulling, you’ll have really nice hair, Star.’ And you know, I’m just like, ‘Believe me, I want to, out of everybody else, I want to. I want to have hair, my own hair.’“
Like the trichsters in my study, I have been asked this question more times than I can count. There is currently no intervention—pharmaceutical, behavioral, or therapeutic—that shows consistent efficacy in clinical trial. Cognitive Behavioral Therapy (CBT) and Habit Reversal Training (HRT) have inconsistent findings but are the current go-to therapeutic interventions. The most promising medication is an amino acid called N-Acetylcysteine (NAC), which had 44% efficacy in reducing pulling urges in a relatively small clinical trial. Though NAC didn’t help me, there was no downside to trying it—I cannot say the same for the cocktail of anti-depressant and anti-psychotic medications prescribed by my psychiatrist in high school. Those made me tired and irritable but had no effect on my pulling.
The shame and embarrassment of having trich are reinforced by a question that is more of an accusation: “Why don’t you just stop?”
iStockPhoto.com // Aiman Dairabaeva
The question, “Why don’t you just stop?” assumes that I could stop if I tried harder or wanted it badly enough, and because I can’t stop, again I am to blame.
Beauty Work
In their research, sociologists Samantha Kwan and Mary Nell Trautner explore the beauty work that individuals engage in to elicit the rewards (and avoid the sanctions) that accompany physical appearance and attractiveness within our social system. For instance, studies show that conventional beauty is often equated with greater peer acceptance and associated with positive traits such as perceived talent, expertise, and social competence. Conversely, unattractive individuals, or those who deviate from traditional beauty standards, are subject to stigma and discrimination. This means that appearance is connected to social outcomes, including success in education, where student attractiveness is positively correlated with teacher evaluations of student intelligence. In healthcare, unattractive individuals receive poorer treatment and are subject to stereotypes (e.g., fatness equated with laziness), and in law, attractive defendants are less likely to be caught, less likely to be reported if caught, and if their case goes to court, are more likely to be granted leniency. Thus, individuals frequently engage in labor intended to increase physical attractiveness with the hopes of gaining the social and institutional advantages associated with beauty.
Many trichsters are experts at hiding the effects of our pulling. We use makeup, strategic hairstyles, hats and scarves, and anything else we can think of to cover or disguise our pull areas. Our beauty work can feel constant—Emily, a White woman who pulls from her eyebrows and eyelashes, reflected on her makeup use: “I have makeup stashes everywhere so that I can touch up my brow if I find myself touching my eyebrows too much. Like, during the workday, I’ll actually pull out a mirror and see if I’ve rubbed off too much makeup and reapply it.” Like Emily, I also kept caches of eyebrow pencils everywhere and frequently checked to make sure my drawn-on eyebrows had not rubbed off. To this day, I still have one pencil in a box in my office and another in my work bag. I have not used them since I had my eyebrows microbladed (a form of tattooing), but I cannot bring myself to abandon them, either.
The beauty work trichsters do to conceal our trich has two dimensions—it is meant to hide both the cause and the effect of our thinning, patchy, or bald pull areas. Hanna, a biracial (White and Japanese) woman who worked in retail, had several hair pieces and wigs that she used to conceal her scalp pulling while at work. “I felt like, whenever I went there, I had to be pretty, I always had to wear my hair cute, and when people would tell me how beautiful I am... I’d kind of think in the back of my head, ‘Haha you have no idea. If I told you, you wouldn’t think that anymore.’“ Hanna understood her beauty as being contingent on the concealment of her bald spots as well as their cause—she feared that if others knew she pulled out her hair, she would no longer be considered attractive.
Celebrity Trichsters
In recent years, mental illness has become somewhat more accepted in U.S. society. For example, Demi Lovato, Selena Gomez, Ryan Reynolds, Miley Cyrus, Lady Gaga, Zayn Malik, and Kerry Washington are just some of the celebrities who have openly discussed their histories dealing with depression and anxiety, which continue to co-exist with their beauty. A few celebrities have publicly discussed their experiences with trich, like actress Olivia Munn (eyelashes) and Victoria’s Secret model Sarah Sampaio (eyebrows), though both are considered conventionally beautiful and are able to use socially acceptable—if not expected—means of concealment for their gender presentation and line of work. Munn wears false eyelashes, and Sampaio fills in her brows.
Perhaps the most public portrayal and discussion of trich comes from comedian Amy Schumer, who included her experience wearing a wig to high school due to her trich (scalp) in her 2022 autobiographical drama, “Life and Beth.” In an interview with Howard Stern, she said wearing the wig was “humiliating,” that she felt “ugly and unlovable,” and that she frequently ate her lunch in the nurse’s office to avoid being ostracized. In the interview, Schumer revealed that she still pulls from her scalp, referring to it as a secret she has kept for many years, and that if it weren’t for the hair extensions she was wearing, she “wouldn’t be able to be on TV.” She went on to say, “I am lucky that extensions have become so normalized—every woman you see on camera in any movie is wearing a wig or has a lot of added hair. That’s just how it works in the business—it’s not even strange.”
Importantly, celebrities are better positioned than most to easily afford the costs associated with concealing hair loss. Schumer’s brand of comedy (although controversial among feminists) is built upon self-deprecating humor and the critique of beauty norms, but her representation of trich reinforces the dual purpose of concealment—she can maintain the expectations of long, full, feminine hair while also keeping the “secret” of her ongoing struggles with trich. That she can easily pay the continuous costs of this secret-keeping speaks to yet another inequity in navigating public spaces with a visible mental illness.
On “Me-Search”
I am lucky that I have built a community of people who support me and help to give me confidence even when I am feeling most vulnerable due to my trich. However, conducting research on trich as a trichster has its own complications—How will I navigate academia as someone researching my own diagnosis while also concealing its effects? Pursuing this research means I have to push against the academy’s resistance to “me-search” and to the devaluation of scholars with misunderstood, stigmatized conditions.
The reality is, academia—including sociology, where the study of stigma originated—is not immune to perpetuating the same types of stigmatization and othering that exist in broader society. Those of us who are both researchers and subjects of various social phenomena—racism, ableism, and transphobia, in particular—are frequently marginalized when our work is dismissed or undervalued by our peers within the academy. We are considered biased in a world that privileges the myth that research can be objective, that we can and should remove ourselves from the people and the phenomena that we study. I believe, however, that my experiences with trich have given me the ability to more meaningfully examine and reflect upon how the perception of mental illness and violation of beauty norms co-construct each other as deviances because I, like my participants, have experienced it first-hand.