On 6 September, at the District Court in Sydney, Australia, Richard Haynes was sentenced to forty-five years in prison for sexually abusing and torturing his daughter, Jeni. The case made international headlines, although not because of the depravity of the crimes which, sadly, would not usually have received that level of media attention. What was unique about this case was that when Jeni Haynes, now aged forty-nine, appeared in court to testify about the abuse she had suffered as a child, she did so while expressing several of the 2,500 personalities that she describes as living within her body.
Jeni Haynes has a diagnosis of Dissociative Identity Disorder (DID), although most people are more familiar with the older name for the condition, Multiple Personality Disorder (MPD)—I’ll refer to both from now on as MPD/DID. The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) stipulates the following as the primary criterion for diagnosing the condition:
Two or more distinct identities or personality states are present, each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self.
These shifts in “personality states” must be accompanied by amnesia, including, crucially, an inability to recall certain traumatic memories. A sufferer from MPD/DID thus appears to have multiple people—usually referred to as alters—living within her body and will regularly switch between each of these alters, giving her access to different memories, as well as different biographies and emotional dispositions. Jeni Haynes recounts that the first distinct personality which developed in her was that of a four-year-old girl called Symphony, who would go on to testify in court more than forty years later. Over the course of many years of abuse, Haynes developed hundreds and eventually thousands of other personalities, each of which held a particular piece of traumatic memory.
The theory behind MPD/DID is that creating multiple personalities can be a way for the human mind to cope with the effects of trauma, particularly during childhood. By splitting off and locking away awful memories within the form of a separate personality, the patient can protect herself from emotional distress. MPD/DID is strongly linked to child sexual abuse, with something in the region of 90% of patients reporting such experiences.
MPD/DID was a psychiatric phenomenon that appeared suddenly in the 1970s, following the release of Sybil, a book (and later a film) that portrayed a woman who had developed multiple personalities as a result of childhood trauma. Within a short time, the condition became astonishingly well known. More people were diagnosed with MPD/DID in the five years prior to 1986 than in the preceding two centuries. But then, just as suddenly, it disappeared. Although there are still patients such as Jeni Haynes, who carry a diagnosis of MPD/DID, the number of new diagnoses dropped off sharply in the mid-1990s and, over the course of that decade, public and clinical interest in the condition declined rapidly. A review of the scientific literature between 1984 and 2003 demonstrates the steep rise and fall of a condition which, as the authors note, does not currently “command widespread scientific acceptance.” Even in 1999, at the tail end of the period of enthusiasm for MPD/DID, a survey of American psychiatrists revealed that only about one quarter believed that the diagnosis was “supported by strong evidence of scientific validity.” This highly controversial condition had only a brief period of acceptance among mental health professionals. Nevertheless, MPD/DID captured the public imagination, not least because of its exciting potential as a narrative device: fiction of the period, including the film Primal Fear and the novel Alias Grace, featured the condition prominently.
To understand why the MPD/DID phenomenon was so influential, it is crucial to understand the historical and political context in which it emerged. In the 1980s, MPD/DID was closely associated with the supposed existence of a network of satanic child sexual abuse cults, whose practices included cannibalism, child murder, and necrophilia. This was a phenomenon now sometimes called the Satanic panic. Two groups in particular became fierce advocates for the existence of such cults: Christian Evangelicals in America, and a subsection of feminists across the western world. Both sets of activists insisted not only that such cults existed, but that they were far more widespread and influential than anyone in authority was willing to accept. When self-described victims of the cults began to manifest symptoms of MPD/DID—and to speak at specialist conferences, write in publications devoted to the phenomenon and publish fractured biographies of their many personalities—their advocates saw such unusual symptoms as the inevitable consequence of the crimes they had suffered. It was not a sign that perhaps the movement was headed in a worrying direction: it was further proof that they were getting closer to the truth.
Satanic panic created an antagonistic binary, which still persists to this day, between those who believed in the existence of the cults, and those who didn’t. It was perversely difficult to adopt a position somewhere in between—to suggest, for instance, that, although the apparent cult victims had experienced sexual abuse, which had caused them long-term trauma, the satanic elements of their accounts were likely exaggerated or invented, the result of social contagion. From the perspective of the most committed believers, such a nuanced position was unacceptable, since to express any scepticism about the accounts of cult victims was to disbelieve all victims of abuse, satanic or not. For feminists, believing accounts of sexual abuse without question has long been an important political commitment: a reaction against a dominant culture which is typically disbelieving. I have written elsewhere about the incentives that exist within political communities that can encourage activists to adopt more and more extreme ideological positions, in defiance of evidence or common sense. These incentives were at play at the height of the MPD/DID phenomenon, and did a great deal to push otherwise sensible people towards accepting claims that, in retrospect, look bizarre. Believing the most implausible claims made by victims and their advocates was a way of demonstrating one’s position as one of the goodies, set against the baddies, who were considered to be on the side of the abusers.
We can now see, with the benefit of hindsight, that MPD/DID is an example of a culture-bound syndrome, an anthropological term for a psychiatric condition that is unique to one culture and historical time period. Examples from other parts of the world include Amok, a condition found in Malaysia, in which sufferers are understood to suddenly become extremely violent towards anyone in their immediate vicinity, having never previously shown signs of aggression. Another well-studied example is Dhat, a condition of the Indian sub-continent, in which men report physical weakness and impotence as a result of semen supposedly leaking out of their bodies when they urinate. Culture-bound syndromes have long been a source of fascination for anthropologists, as they often highlight crucial cultural differences in understandings of the relationship between mind and body.
Such conditions are to be found in the western world too, although they may be harder for westerners to identify. Edward Shorter is a historian of psychosomatic illnesses, who has studied the psychiatric conditions of nineteenth-century Europe, including hysteria and neurasthenia, which fit the profile for culture-bound syndromes. He argues that these historical forms of madness, which we now view as rather bizarre, were the result of patients gravitating towards clusters of symptoms recognised by the medical establishment of the day:
Patients want to please doctors, in the sense that they do not want the doctor to laugh at them and dismiss their plight as imaginary. Thus they strive to produce symptoms the doctor will recognise.
Hence, patients unconsciously draw from what Shorter terms “the symptom pool”—the limited array of symptoms that are considered credible, not only by medical professionals, but by other members of a given society. For young women in nineteenth-century Vienna, this might mean sudden limb paralysis. For their counterparts in 1980s America, manifesting MPD/DID was a far more acceptable way of expressing trauma. Dogmatic therapists, who were convinced not only that MPD/DID was a real condition, but also that it was far more common than anyone else realised, subtly encouraged their patients to manifest the symptoms. Allen J. Frances, chair of the group who put together the fourth edition of the DSM, at the height of the MPD/DID phenomenon, writes now that the role of social contagion is indisputable:
Having seen hundreds of patients who claimed to house multiple personalities … In every single instance, I discovered that the alternate personalities had been born under the tutelage of an enthusiastic and naive therapist, or in imitation of a friend, or after seeing a movie, or upon joining a multiples’ chat group—or some combination.
People suffering from culture-bound syndromes such as MPD/DID are not liars or fakers. Their emotional distress is absolutely real and their manifestation of behaviours drawn from the “symptom pool” is sincere. In looking back at the MPD/DID phenomenon, and satanic panic, we must be careful not to mischaracterise either side of the conflict as villains or fantasists. The reality was far more complex.
It is now known that patients diagnosed with MPD/DID are clinically indistinguishable from those diagnosed with Borderline Personality Disorder (BPD). This condition is characterised by emotional volatility, propensity to self harm, extreme vulnerability to negative emotions and difficulty in maintaining stable relationships. It is mostly found in women: it seems that men with similar tendencies are more likely to manifest Antisocial Personality Disorder. One compelling theory about personality disorders is that they should be conceptualised as extreme personality types. Looking at BPD sufferers in terms of their Big Five profiles—their key personality traits according to the gold standard of psychometrics—reveals that they have a dysfunctional combination of high neuroticism, low agreeableness and low conscientiousness. These personality features, when found together, tend to produce the symptoms that we see in BPD, often with disastrous results for the patients, who may struggle to function in their personal and professional lives.
BPD symptoms are the products of both nature and nurture. A person born with a BPD personality profile who enjoys a stable life may be able to come to terms with her emotional volatility. A person born with a BPD personality who experiences some forms of trauma will likely suffer terrible anguish—more so than someone who experiences exactly the same misfortunes, but whose personality is more stable.
For instance, a person with BPD who suffered from child sexual abuse will struggle enormously to recover from the trauma. She may manifest her unhappiness through various means, self harm primary among them, and, if she happens to come to maturity at a historical moment when a psychiatric fad like MPD/DID is in ascendence, she may well find herself drawn to it. This is particularly true if she is suggestible by nature. BPD causes terrible mood swings, often on a rapid cycle, and it is easy to imagine how someone who sometimes feels like a different person in her volatile emotional states might be persuaded that she really is a different person when she is angry, depressed, elated and so on. It can offer a compelling narrative, allowing a person to understand her experiences in a way that seems to make sense.
I do not in any way condemn people diagnosed with MPD/DID for embracing the certainty that the condition seems to offer them. When people are suffering from emotional pain that feels unendurable, they tend to reach for anything that seems to offer hope of a solution. If there is anyone who deserves condemnation, it is the minority of mental health professionals who promoted MPD/DID in the 1980s and 1990s, ignoring accumulating evidence that the concept was unsound and continuing to diagnose patients with the condition even as its manifestation became ever more extreme. There is now evidence that their actions caused real harm, as patients diagnosed with MPD/DID were more likely to attempt suicide than comparable patients who received a different diagnosis. But as for those other people—psychiatrists, social workers, feminists, the friends and family of sufferers—who enabled the MPD/DID movement, but were not its authors, a more nuanced assessment is needed. Psychiatric fads develop because of the cognitive biases innate to human beings. We are all vulnerable to being swept along by them, in defiance of evidence, particularly when they appeal to our tribal identities. The only way of protecting against this tendency is to learn from history and to keep our wits about us.
And this is no less true in the present day. Culture-bound syndromes are to be found in every part of the world and in every historical period. MPD/DID is only one recent and dramatic example. In an earlier era, anthropologists tended to view these conditions as unique to uncivilised societies. We now know that this is not the case.
Aside from MPD/DID, there are a number of conditions recognised by contemporary Western psychiatry that seem to fit the culture-bound syndrome model. Anorexia nervosa is one example that has been a source of interest to anthropologists, and so-called Rapid Onset Gender Dysphoria (ROGD) is another—more controversial—possibility that has only recently emerged.
ROGD is a gender identity disorder first described by Lisa Littman, an assistant professor at Brown University School of Public Health, in a paper published in 2018. As part of her research, Littman surveyed the parents of young trans people and asked about the circumstances in which their children had come out as trans. She found that a large proportion of these young people had announced their intention to transition suddenly, out of the blue, having previously shown no signs of cross-sex identification. Littman also notes that:
The expected prevalence of transgender young adult individuals is 0.7%. Yet, more than a third of the friendship groups described in this study had 50% or more of the AYAs [adolescents and young adults] in the group becoming transgender-identified in a similar time frame, a localized increase to more than 70 times the expected prevalence rate.
The young people who were the subjects of Littman’s research had also often suffered from serious mental health problems, which in many cases worsened following transition. She tentatively concluded that these findings suggested that social contagion might have a part to play in the recent huge rise in the diagnosis of Gender Identity Disorder in young people, particularly natal females. Littman’s research suggested that ROGD might be an example of a culture–bound syndrome, in which young people were drawn to identify as trans as a way of expressing deep unhappiness with and alienation from their bodies. The claim by proponents of ROGD is that the symptom pool available to people in distress now includes cross-sex identification.
The furious response to Littman’s paper among trans activists generated international headlines. Critics suggested that Littman’s research sample had been unrepresentative, given that she had recruited participants from online forums with a gender critical bias. They also objected to her focus on parents’ accounts, rather than on those of the young people themselves. Trans activist and academic Julia Serano was particularly critical of Littman, writing that the concept of ROGD served to provide “reluctant parents with an excuse to disbelieve and disaffirm their child’s gender identity.”
And yet increasing numbers of detransitioners are now speaking publicly about the effect that social contagion had on their decision to come out as trans, and the attendant suffering that they have experienced as a result, which seems to support the ROGD hypothesis. They attest to the aggravating effect of a political climate in which psychiatric experts are censured for expressing any scepticism whatsoever about the trans movement. As one young detransitioner writes:
I tried my best to find books that discussed the issue critically and offered opposing views, but all I found were pro-transgender authors. That left me with the obvious conclusion: If all the “experts” were in favor of transition, why not do it?
We have no way of knowing at this stage how representative these people’s experiences are, but their accounts should give us pause. After all, it would not be the first time that a contagious psychiatric phenomenon has caused serious harm to vulnerable people, as we have seen with the MPD/DID movement.
Other researchers have expressed support for Littman’s conclusions, among them Ray Blanchard and Kenneth Zucker, two of the leading experts on the treatment of Gender Identity Disorder. Moreover both Blanchard and Zucker have explicitly compared ROGD with MPD/DID. Some of the similarities are indeed arresting. Both the trans movement and the MPD/DID movement arose suddenly, although the groundwork had been laid over a long preceding period. Both saw a huge spike in diagnoses among young, vulnerable females. Both made extreme claims about the nature of identity, which seemed to defy conventional wisdom. Both were (and continue to be) politically charged, with an established dichotomy between goodies who are on the side of suffering victims, and baddies who refuse to accept those victims’ accounts of themselves.
It is this last point that can make discussion of culture-bound syndromes so difficult. A diagnosis such as Gender Identity Disorder or MPD/DID can be a comfort to people in deep distress, and it may seem callous to undermine their efforts to define their suffering on their own terms. Affirming the claims of vulnerable people may seem to be the compassionate option, as well as—in some cases—the most politically expedient.
Up to a point, I agree with this perspective. I believe that if Jeni Haynes prefers to understand herself as a sufferer of MPD/DID, then she should be free to do so, and it is right that the Australian courts allowed her to testify in the way she preferred. I have no doubt whatsoever that she told the truth about the terrible abuse she experienced at the hands of her father. Similarly, if a young person chooses to identify as trans, they should of course be treated with respect and permitted to describe themself in whichever way they choose.
However, we must be vigilant against the potential harms of psychiatric phenomena that offer false certainty to vulnerable people. Fear of causing offence should not be a barrier to rigorous research, particularly when patients are considering undergoing irreversible medical interventions. It is not kind to promote such conditions without evidence, nor is it cruel to be sceptical of them. Sometimes, in fact, scepticism can be a form of kindness.