The young woman sitting in front of me is sure she is dead. It – her dying – happened two weeks ago, she says. Now she simply doesn’t exist.
I check the scrawl of referral notes, which don’t say anything about this. There isn’t much time; I’m supposed to administer her a battery of cognitive tests, dictate a brief report, and move on to my next patient. I want to reassure her, but her eyes dart about my office – small, over-lit and cluttered with stacked folders and a tangle of dusty cables.
‘Is this heaven?’ she asks.
It’s not clear how best to respond.
I’ve spent my professional life trying to make sense of cases like these: delusions. Part of the challenge is how to draw the line between who a person is and what has gone wrong with them. In the clinic this is often straightforward, and as a clinician or theorist trying to understand such cases there is at least a measure of certainty, and the possibility of detachment. But these questions are increasingly contested in cultural spaces – and sometimes they must be confronted not just at work, but at home.
Many of the most fascinating clinical examples of delusion concern personal identity and bodily integrity. Some patients look in the mirror and see a stranger; others believe their loved ones have been replaced by physically identical impostors. In one strange case, published in 2018, a man presented to an Australian emergency department convinced that his penis had been stolen and substituted with someone else’s.
Are delusions merely the dysfunctional products of a broken brain? Or might they in some cases be functional – purposive constructions that protect the self? Sigmund Freud famously described a delusion as a kind of psychic bandage, and many others have followed suit. Psychoanalytically inclined theorists have construed the conviction that you are dead as a paradoxical defence against death: if you are already dead, you have nothing to fear from dying. Others in the Freudian tradition have cast a young woman’s belief that her father has been replaced by an impostor as a way of denying that her sexual feelings for him – supposedly rooted in ‘penis envy’ – are incestuous.
Freud’s ideas are easy to pillory and caricature, and in lectures on the Freudian approach to psychopathology I have sometimes lightened the mood with an anecdote about my kids:
Two-year-old [noticing older brother’s penis in the bath]: ‘I want a willy.’
Seven-year-old: ‘Girls don’t have willies. Boys have willies, and girls have pyjamas.’
Yet the idea that delusions can serve a psychological purpose isn’t always far-fetched. And, of course, the idea that beliefs can serve emotional functions is not confined to clinical disorders. I’ve often wondered about the emotional underpinnings of my own convictions, particularly those concerning God and religion. Some psychologists have argued that atheism is driven by feelings of abandonment, perhaps from losing one’s father at a formative age. This theory doesn’t enjoy much contemporary support, but for a while I was quite taken with it: my dad had died suddenly as I was on the cusp of adulthood.
One prominent commentator has claimed that gender dysphoria is the clearest case of social contagion in history
That summer, I got a job on a gold mine, in the Australian outback. The work was hard, and I drank a lot. But for a while the new environment offered escape from the palpability of my dad’s absence. As the weeks passed, however, something began to give. While working a night shift, hurtling through the dark desert in a fuel truck, I felt him there with me in the cab. Afterwards I became fixated on the jarring discordance between the way we react to death and the comforting stories we tell about it. If it was true that my dad was in heaven, then why all the grief and grim faces? Why hadn’t my relatives arrived with beaming smiles to impart the good news about where he had gone? For a short while, the rawness of grief opened me to really believing, and I wanted to convince my family that his death was something wonderful, that we should feel joy. I was approaching an edge. But then I stepped back.
Thereafter, rigid analysis and brittle abstraction became both shields and weapons. I identified as a scientist and an atheist, and relished taking a scalpel to the Christian tradition I had been raised in. As a graduate student, I wrote a paper provocatively titled ‘Hallucinating God?’, arguing that religious belief is delusional. Part of the argument was that typical religious beliefs – virgin births, transubstantiation, bodily resurrection – often violate just as many established scientific principles as clinical delusions do. God, I was convinced, simply doesn’t exist.
However, the ‘bible’ of psychiatry – the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) – specifies that religious beliefs are not delusional because they enjoy wide cultural acceptance. On this view, the impostor-penis patient was delusional not simply because his belief was false and harmful (he had cut and burned his penis), but because it lacked cultural scaffolding in Australia.
I was impatient with this perspective. After all, similar beliefs – also false, also harmful – have at times arisen in shared, collective contexts. Did that mean they weren’t delusions? So-called ‘penis panics’ have been reported in various countries. Such ‘collective delusions’ demonstrate that harmful ideas, sometimes untethered from biological reality, can gain a cultural foothold.
According to some commentators sceptical of the concept of gender identity, the recent rise in gender dysphoria is a Western ‘culture-bound syndrome’, part of a lineage of culturally mediated expressions of distress, from penis-theft scares in Asia and Africa to the collective delusions catalogued in Charles Mackay’s classic book Extraordinary Popular Delusions and the Madness of Crowds (1841). Indeed, one prominent commentator has claimed on social media that gender dysphoria is the clearest case of social contagion in history.
Given the hard-nosed mindset I had spent decades cultivating, I could understand the pull of claims like these.
A summer’s night, and I’m reading to my younger child, who is now seven, in the soft glow of a rabbit-shaped lamp. One of the characters in the story describes something as ‘queer’, and I’m immediately asked to explain this word. I say it means strange or unusual, but after a moment I add that it also has another meaning: that some people use it to describe themselves, people who might be gay or not comfortable with their gender.
‘Am I queer?’
‘I don’t know, love, that’s for you to decide.’
‘I’m not comfortable with my gender.’
This has been clear for years by this point. I no longer tell the willies-and-pyjamas story in class.
‘It’s not your fault, Dad. I might have selected the wrong gender in Baby Heaven.’
I learn that Baby Heaven is an endless playground of fun where you play until you’re born. You arrive on a flying bus after God creates you, and while you wait to be born you choose your gender, eye colour and skin colour. God chooses other things, like which country you’re born in or which parents you’re born to.
I can’t help seeing the rise in trans identification not as a wave of delusion but, in part, as a wave of visibility
I switch off the lamp, and we study the sticker constellations on the ceiling: a makeshift Southern Cross, an improvised Saucepan.
‘I’m glad I got you and Mum as parents.’
Memory is fallible, but this moment still feels vivid and glimmering. A bulwark against what might lie ahead.
As a parent, scenes from the boarding school I attended increasingly return to me, like scraps of a language you once spoke emerging unbidden on return to that country.
No one in the boarding house would have dreamed of admitting to being gay, but signs of homosexuality were scrupulously monitored. Mornings could be tough, especially in the earlier years. An older boy would burst in and tear your blankets off, and you were ushered straight into a communal shower. The only respite was a quick visit to the urinal on the way to try and kill off the erection you had inevitably woken with. Taking it into the shower with you was unthinkable.
Although pornographic magazines were traded fairly openly (care was taken to avoid housemasters, who would confiscate them), there was an extremely strong taboo against masturbation. Presumably we were only reading these magazines for the articles. This taboo called for extreme caution. One unfortunate boy who was caught in the act became a social pariah. While I wish I could say that I’d stuck up for him, or even that I’d empathised, my attitude towards him was more a mix of anthropological curiosity and contempt.
It’s clear to me now that the strikingly low prevalence of homosexuality and masturbation in the boarding house reflected taboo rather than true absence. One of my closest friends there later came out as gay; I had absolutely no inkling before he phoned to tell me. He had somehow survived years of pressure to keep this invisible. While trans and gender-questioning youth still face a hostile climate, bullied today at twice the rate of their peers, I can’t help seeing the rise in trans identification not as a wave of delusion but, in part, as a wave of visibility – less a contagion of identity than of permission to be seen.
‘Dad, were you happy when you realised I was trans?’
A year or two has passed. We’re in the changing room of our local community swimming pool. It’s not really a conversation I want to have in such a public place.
‘Let’s just finish getting dressed, and we’ll talk about it in the car.’
Back in the car, I sit in the driver’s seat. My son climbs in behind me, and when the door shuts, I start to talk. I choose my words carefully.
I don’t say that the experience of being his parent has forced a sometimes-uncomfortable realignment of my own beliefs and identity, that it has surfaced some of my own prejudices and many of my fears.
I don’t admit that, for a while, I’d been irritated by phrases like ‘assigned at birth’, or that I’d resented the growing pressure to state pronouns in email signatures and social media bios, that I’d considered this performative. That it took having a deeply personal stake to consider what such practices might mean to people like him.
Rather than ceding authority for who he is to God or biological happenstance, he claims it for himself
I don’t talk about how I’ve been distressed by the viciousness of the rhetoric I’ve seen online, but humbled by the kindness and unhesitating acceptance of people in our own community. I don’t say that I recognise now that people’s beliefs and identities are not my intellectual playthings, not just specimens on my board. That they can be vessels of anguish and fragile, questing hope. I don’t tell my son that I’m awed by his courage to be himself.
I do try to explain that, as a parent, you want your child to be who they are, without having to pretend, to wear a mask. But at the same time, you worry about them having a difficult path through life.
I talk for a minute or two, and when I stop, there’s a silence.
‘So, does that make sense?’
I’m worried I’ve upset him.
Another silence. I turn around, and he looks up.
‘What?’
He hasn’t been listening at all. Must have tuned me out almost immediately.
A mix of emotions. Annoyance, obviously – I’d spoken with care, and thought I’d acquitted myself well.
But mostly I’m relieved. For the time being at least, this subject is not the be all and end all.
What I find quietly inspiring about my son’s musings on Baby Heaven is also what frightens me: rather than ceding authority for who he is to God or biological happenstance, he claims it for himself. His cosmology is a metaphor for self-authorship, but also for accountability. It opens the door to pride, if others acknowledge what is authored, but also to shame or even erasure, if they do not.
A book from my own childhood that my kids have enjoyed is an Australian classic: The Bunyip of Berkeley’s Creek (1973) by Jenny Wagner. The titular bunyip wanders about, asking others (a platypus, a wallaby, an emu) what bunyips look like.
‘Horrible,’ they say, with ‘horrible feathers’ and ‘horrible fur’.
When a scientist tells the bunyip that bunyips ‘don’t look like anything’ because they ‘simply don’t exist’, his reaction is mournful but understated: ‘What a pity.’
A common gender-critical refrain is that ‘There is no such thing as a transgender child.’
Perhaps, for such commentators, this denial is a swish of the lab coat, an abstract intellectual dismissal. But to a trans child, it may land as something closer to annihilation.
What a pity.