From ‘chemical imbalance in the brain’ to ‘born in the wrong body’

This essay was partly inspired by my recent article for UnHerd and by Carrie Clark’s remarkable piece 'How I cured my ‘mental illness’, which I strongly recommend reading in full (links at the end).

I remember the exact moment I first heard that the “chemical imbalance” theory of depression wasn’t actually proven fact. I was a third-year psychotherapy student at the time. A lecturer casually mentioned that there was no solid evidence that depression was caused by a serotonin deficiency in the brain. She delivered this information in the relaxed tone of a weather forecaster announcing mild rain across Ireland. I looked around the room expecting outrage. Nothing. Everyone nodded wisely, as though they’d known this all along.

My hand shot up. “Sorry,” I said, “what?” It felt like discovering halfway through pilot college that the central theory explaining how aeroplanes fly had never really been proven, but the aviation industry preferred not to dwell on it.

That moment stayed with me because it revealed how psychiatry speaks in the confident language of medicine while operating in a world of metaphor, interpretation, and educated guesswork. That doesn’t mean mental illness isn’t real. Anyone who has encountered schizophrenia, bipolar disorder, severe anorexia, or crushing depression knows human beings can suffer in terrifying and mysterious ways. Some people are undeniably helped by psychiatric medication. I am not a fully paid-up member of the anti-psychiatry movement. But I have become increasingly sceptical of how speculative theories are so often presented to the public as settled science. I am also grateful that ‘critical psychiatrists’ have emerged in this field, just as ‘gender-critical psychiatrists’ have begun speaking out about the startling lack of evidence underpinning trans medicalisation.

Psychiatry occupies a strange territory unlike almost any other branch of medicine. There are no blood tests for grief. No MRI scans for existential despair. There is no lab result confirming that a teenager’s melancholia is definitely a “clinical disorder” rather than simply modern adolescence colliding with the bitter difficulties of existence. Too much TikTok, pornography, family breakdown, social anxiety, and too little sunlight might seem lightweight reasons for a young person to feel overwhelmed, but they’re not.

And yet the tendency in our culture to describe every form of suffering through a diagnostic lens is creating more problems than it resolves. Profound sadness is more often perceived as “clinical depression.” Shyness is increasingly understood as “social anxiety.” Ordinary unhappiness caused by difficult life circumstances is more often than not pathologised, diagnosed, and often medicated.

Until relatively recently, emotional pain was generally understood as a signal that something in your life was wrong. You were lonely in your marriage. You hated your job. You were grieving. The suffering, however unpleasant, was usually connected to reality and invited reflection, change, endurance, or the gradual search for meaning.

Today emotional distress is increasingly interpreted differently. Sadness, anxiety, alienation, confusion, and despair are more likely to be understood as symptoms of a malfunction in the brain requiring diagnosis and treatment. Once a society begins interpreting suffering primarily through the language of pathology and medical intervention, the explosion in gender dysphoria and trans medicalisation becomes far easier to understand. Gender medicine did not invent the therapeutic logic of affirmation. The wider culture of mental health had already become increasingly organised around affirming feelings, identities, and subjective experience.

The rise in trans identification did not emerge in isolation. It emerged from a much broader cultural and psychiatric shift in which growing numbers of ordinary human experiences came to be understood through diagnostic frameworks. Distress increasingly came to be perceived as evidence that something inside the person had malfunctioned and required correction. Gender dysphoria was part of this broader trend. Trans activism arrived at a moment when Western culture had become primed to interpret suffering through the language of pathology, diagnosis, and medical treatment. In that environment, explanatory narratives that transformed suffering into medically validated identities acquired enormous cultural power.

These unfalsifiable, unverifiable theories are remarkably difficult to argue against. “Born in the wrong body” functions much like the “chemical imbalance in the brain” theory. Both are emotionally powerful phrases wrapped in the language of science. Both offered neat explanatory stories for forms of suffering that are often complex, ambiguous, and difficult to comprehend.

Most importantly, both frameworks relied on metaphor, while the public interpreted the metaphors literally. We were apparently never meant to believe that depression was caused by a chemical imbalance in the brain, nor that people were literally born into the wrong body, despite hearing both phrases repeated endlessly as explanatory truths. It is remarkable how profoundly these metaphors shaped public understanding of both conditions.

The current understanding of gender dysphoria emerged within a much larger psychiatric and cultural landscape. Some people insist that “gender dysphoria is not real,” as though the absence of objective biomarkers somehow disproves the existence of suffering. But by that standard, much of psychiatry would collapse overnight. Depression is real. Anxiety is real. Psychological suffering is profoundly real. Yet none of these conditions - including gender dysphoria - can be confirmed through a blood test or brain scan. What we largely have instead are subjective descriptions organised into rudimentary diagnostic checklists.

Gender dysphoria certainly exists as a form of suffering. Of course it does. The human mind can lead people to many strange and painful places. I have met countless people profoundly distressed by their birth sex, and I experienced that distress myself as a child, so I can easily empathise.

The mistake lies in assuming that the treatment for gender dysphoria is trans medicalisation. Feeling alienated from your body does not necessarily mean you were born in the wrong body, nor that you require extreme body modification, just as feeling consumed by hopelessness does not prove the existence of a serotonin deficiency, nor that SSRIs are the only possible response.

The rise in trans identification emerged during an era in which ordinary human distress came to be routinely interpreted through the language of diagnosis, trauma, pathology, and identity. At the same time, adolescence itself has been transformed by smartphones, social media, and a multi-billion dollar industry determined to keep us online.

Over the past few decades therapeutic culture has expanded far beyond the treatment of severe mental distress and into ordinary life. Today therapy has become as common as joining a gym. Many detransitioners I encounter have seen countless therapists. Double digits are not unusual. Yet all this therapy, diagnosis, and medication does not appear to have helped very much.

Every age creates stories to explain suffering, including ours. We have had demonology, bloodletting, witchcraft, possession, phrenology, and lobotomy. Modern people flatter themselves that we are uniquely scientific while often speaking about mental health through concepts that remain surprisingly fuzzy, culturally shaped, and philosophically loaded.

The helping professions want to help. Doctors, therapists, psychiatrists, and psychologists usually enter these professions because they want to reduce suffering. But perhaps that’s what makes them more reluctant than most to say, “I do not fully understand this, and I’m not sure I can help you.” And yet they need to learn how to say this, and to say it whenever it is true.

Suggested Reading

This essay was partly inspired by my recent article for UnHerd and by Carrie Clark’s remarkable piece ‘How I cured my ‘mental illness’, which I strongly recommend reading in full.

For readers interested in exploring the broader debates around psychiatry, diagnosis, medicalisation, psychological suffering, and gender identity in more depth, the following books and thinkers are worth engaging with, whether one ultimately agrees with them or not.

• Saving Normal by Allen Frances
  Written by the former chair of the DSM-IV task force, this book warns against diagnostic inflation and overmedicalisation.

• Man’s Search for Meaning by Viktor Frankl
  A powerful reflection on suffering, meaning, and human resilience.

• Warning: Psychiatry Can Be Hazardous to Your Mental Health by William Glasser
  A humane and practical challenge to diagnostic culture and overreliance on medication.

• Users and Abusers of Psychiatry by Lucy Johnstone
  A critical examination of psychiatric systems, power, and diagnosis.

• The Divided Self by R. D. Laing
  An influential attempt to understand psychosis phenomenologically rather than purely biologically.

• The Myth of the Chemical Cure by Joanna Moncrieff
  A major critique of the chemical imbalance theory and the modern psychopharmacological model.

• Moncrieff, J., Cooper, R.E., Stockmann, T. et al. The serotonin theory of depression: a systematic umbrella review of the evidence. Mol Psychiatry 28, 3243–3256 (2023). https://doi.org/10.1038/s41380-022-01661-0

• The Myth of Mental Illness by Thomas Szasz
  A foundational critique of psychiatric diagnosis and the medicalisation of human problems.