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Weeding the Body

Trichotillomania and the Unconscious Desire to Pull

ISSUE:  Summer 2019


God spare you the judgment of a fifteen-year-old girl. Recently, one whom I like a lot showed me some pictures of her classmates, slowly swiping left, submitting them to my sentencing and her own. She paused at one photo and used her fingers to zoom in. “She pulls out her hair,” she confided, her voice low with disgust. “It’s so gross.” I couldn’t see anything out of the ordinary, and I told her so. “Her eyelashes,” she said. Indeed, eyelashless, the girl’s face looked slightly bare and denuded, unnerving but not exactly unattractive. I told my friend to go easy. “I just don’t understand why she can’t just stop,” she said, dismissing in an instant both her classmate’s physical appearance and her personal fortitude. Without her eyelashes, this girl was functionally nothing. 

As fate would have it, I knew exactly why she couldn’t just stop. For one thing, I’d spent the last four years researching her condition, known as trichotillomania—the chronic and compulsive pulling out of one’s own hair. For those with trichotillomania, simply stopping is not an easy option, or even an option at all. The act of pulling is compulsive and unconscious, like jiggling one’s leg or biting one’s nails. For another thing, I’m one of those who can’t quite stop. 

As with most medical terminology, the name trichotillomania is Greek in origin, from trikhos and tillein, meaning “hair” and “to pluck,” respectively, and the suffix mania, meaning “madness.” Few people have heard the name of the syndrome, but many I spoke to while researching—most, even—knew someone who has it: “A girl I went to middle school with has that. She had to go to rehab.” “A cousin of mine pulls out her eyebrows.” “My brother used to pluck his hair.” “A woman at work wears a turban to hide her hair loss.” People shared these stories with me eagerly, relieved to put a name to a face, so to speak. But there’s often a shade of pity and befuddlement: Who would do such a thing? 

Anywhere from 0.5 to 4 percent of adolescents and young adults may have some form of trichotillomania, which means the disorder may be as prevalent as anorexia. But the numbers are slippery, and potentially low; the data, as with all medical research, rely on people’s willingness and likelihood to report their symptoms. There have been no large-scale studies of the disorder to date. Those who pull their hair out don’t often report it. They are unlikely to consult with doctors or seek specialized counseling. They aren’t often sent to hospitals. They rarely even suffer pain. In fact, most people who have trichotillomania have probably never heard the term at all. 

Nevertheless, there’s a certain startling uniformity to the narratives of those with trichotillomania, or trich, as it’s called casually within the community (pronounced “trick”). They all incorporate the same tropes, the same moments, the same sensory fixations, revelations and relapses, ebbs and flows and cycles of defiance and shame. For example, most people who do it describe their need to pull as an unconscious desire, like an itch, like a feather to the back of the brain. Once the desire is resisted, it becomes manifest—unbearable, even. They describe the resistance as a constriction in the chest, a heat in the cheek, an ache in the soul. Only satisfying the urge can ease the discomfort. Just as itching calls for scratching, trich calls for pulling.

Most pullers describe their compulsion as a sort of task or game, which centers on the rooting out and removing of “bad” or “wrong” hairs—coarse or wiggly ones that undermine the purity of the whole. One woman described pulling to me as “gardening the hair” and “weeding.” The process is tactile, meditative, intuitive—an exploration of what makes each hair different. Some 10 to 20 percent of pullers eat the hair after plucking it—this is called trichophagia, and it results in dangerous trichobezoars, or hairballs—but a majority, it seems to me, run the hair or sticky root gently along their lips after plucking it. The pull itself is almost always described in terms of pleasure, delight, and revelation; alongside that gentle, severing sting, a heavenly, metempsychic moment of relief: freedom.

“Scratching is one of the sweetest gratifications of nature, and as ready at hand as any,” wrote Montaigne. “But repentance follows too annoyingly close at its heels.” So, too, with trichotillomania. I met dozens of women, and some men, whose trichotillomania has unraveled their lives: lost jobs, lost lovers, the absolute decimation of their self-esteem. And my life? It is firmly intact. In fact, I’d wager that of the many people in my life, maybe a tenth have noticed my pulling, which easily passes for the errant attention most women afford their hair. Do I have trichotillomania? 

My research into trich was driven by a collection of abstract questions: What is the relationship between compulsion and unhappiness? Why is this disorder less known than other disorders? Why does this disorder disproportionately affect women? But perhaps more than any one of these questions, I was driven by a desire to resolve my own sense of purgatory: If trichotillomania does not adversely affect my life, what would it mean to say I “have” it? In other words, when does a bad habit become a problem? 

One Friday morning in April 2015, as late winter gave way to the bracing snap of spring, I took the train from New York City down to Arlington, Virginia, to observe a national assembly of hair pullers, likely the largest deliberate gathering of people with trichotillomania in the world. It was the fourteenth such assembly, organized each year by the TLC Foundation (now called the TLC Foundation for Body-Focused Repetitive Behaviors), an organization dedicated to advancing the understanding of trichotillomania and providing resources to those who suffer from it. From the window of my taxi, I watched the city pass in stripes of pink and brown—it was the weekend when Washington’s thousands of cherry blossom trees erupted into full bloom, and their contemplative, lush silhouettes shadowed the lanes between stocky granite government office buildings. 

The conference was held at the Renaissance Arlington Capital View Hotel, a glassy, mid-range hotel in a row of identical midrange hotels near Washington National Airport. Inside, girls and women swarmed to-and-fro around the registration desk and clustered in small cohorts. The room was overwhelmingly female, and also mostly white, though I spotted boys here and there. The atmosphere was one of affection and eagerness, pregnant with a sense of embarkation, like boarding the bus to summer camp: Many of the girls knew one another from prior conferences—in Newark, Los Angeles, or Orlando—and were reuniting. For others, it was a frightening new step. TLC’s official lime green was everywhere—on the cheap synthetic bags of literature and on the name-tag lanyards. Green lanyards indicated a willingness to be photographed; black meant lens off. 

By the registration table, I watched attendees with long, flowing, full heads of hair pass by. No one seemed afflicted, as far as I could see. Maybe these women control their disorder well, I thought. Maybe they are in remission. Maybe they are wearing wigs. I took my own green bag and lanyard and went into the ballroom for the opening speeches. 

There, it was another story. I was reminded of a frightening scene in the 1990 film adaptation of Roald Dahl’s The Witches in which the title characters peel back their wigs in unison to reveal their angrily mottled pates. In the film, the removal of the wigs signifies the exposition of a terrifying inhumanity. In the ballroom, the image has a different effect—of some intensely vulnerable humanity that usually remains hidden. Parents idly rubbed the backs of their balding children, some as young as eight or nine. Some had tufty strips down their skulls, like a solo pass of a razor. Teenagers had pinned long and thin strands around their heads in complicated ways that didn’t fully hide the bare patches of scalp below. Many of the older women were turbaned or kerchiefed. Some had given up altogether and shaven their heads.

The conference opened with a series of enthusiastic speakers. One sixteen-year-old girl with a full head of curly brown hair, a member of TLC’s “Millennial Taskforce,” told us how the conference’s “tight-knit community” brought her to her closest friends. “I think that is one of the perks of having a BFRB”—a body-focused repetitive behavior —“you get to come to this amazing conference and meet amazing people,” she said, beaming. “If I can, you can, too.” 

After the opening ceremony, the participants broke off into small, targeted sessions. I chose a session called “On Love and Dating for Young Adults,” though some participants looked no older than twelve. We sat in a big circle of metal chairs in an anesthetically baroque conference room off the main lobby. The people in the circle exuded both the coltish insecurity of all teenagers and something more blatantly vulnerable. The moderator, a woman in her late thirties with funky glasses and a severely cut bob, cracked some jokes to lighten the mood. Everyone giggled nervously. 

But the tenor of the session was a far cry from the buoyant opening remarks. Slowly, with trepidation, these young women and men began to reveal their deep anxieties, and respond to one another. Their worries mostly revolved around their perceived desirability or lack thereof. To many of them, a romantic relationship seemed beyond possibility. They debated whether or not they could date someone who also pulls out their hair. Some said they’d only feel comfortable in such a relationship; others argued that the correspondence would be overwhelming. 

One girl stood out to me. She seemed guarded and a little contemptuous of the session, but she expressed herself confidently and articulately. Her face had a cheerful, smooth, all-American look, with bright, nut-brown eyes and bushy brown hair pulled into a high ponytail, but her manner was wary and a little sad. After the session, she told me her story with the kind of practiced self-awareness that betrays a precocious fluency in the language of mental health professionals. 

Nina was twenty. She had been raised in a Virginia suburb, not far from DC, an only daughter born between two sons in a military family. She had been a dancer until the tightly pulled-back buns that dancing demands began to humiliate her. As a sophomore in high school, Nina started pulling out her hair obsessively from her scalp. By her junior year, she’d pulled out so much of her thick brown hair (along the hairline, mostly, front and back) that the bald patches were too large to hide; at the lowest point, in the spring of her junior year, she missed three straight weeks of school. First, they called the truancy officer, and then the school psychologist. The psychologist was useless, she said. “I was such a good student, pulling straight As, and the only time they noticed me was when I stopped achieving.” 

Looking at Nina’s hairline, I couldn’t see any hair loss. Her forehead was broad, though, her hairline deep, covered with a wide cloth band. She told me how she had found pictures of herself as a child with patches of her eyebrows missing. She doesn’t remember pulling them out. The first hairs she remembers pulling were the ones that sprouted in middle school, on her legs and below her belly button. She didn’t see anything strange about the behavior; she didn’t know much about waxing or tweezing, but she had a vague notion of cosmetic hair removal. “I thought—this is fine,” she said. “I’m just doing what other girls do in a different way.”

Nina’s parents were in the process of an acrimonious separation. The pulling got worse, but she didn’t want to add to the stress of the household. In her family, she told me, depression is seen as a sign of weakness: “‘Suck it up, block it off.’ I hated that I wasn’t self-disciplined enough to stop.

“I began to question everything. How can I ever be on my own if I can’t stop doing this? How am I going to ever get a job? How will anyone ever find me attractive?” Around that time, her boyfriend left her for another girl. “When I saw a picture of her, I immediately looked at her hair. And she had such beautiful hair, and I was crushed. I wanted to vomit.” 

What is the point of hair? It protects, of course—swaddles us in warmth and provides a physical barrier, a gentle silken armor, between our bodies and life’s battery of stimuli. Hair is dead, which makes it seem like a strange excretory product, a layer of refuse smothering and soiling our skin. But hair, like sweat, isn’t merely the accretion of our bodies’ extant waste; rather, our follicles (five million, and all present at birth) are specifically and exclusively designed to produce hair, which makes hair more like a gift than a by-product. Like our dank scent and the fluids of our body, hair extrudes, oozes, and unfolds, at once grotesque and erotic. 

Hair is one of the distinct markers of mammaldom, though we’ve evolved to have considerably less of it than our primate progenitors. Humans today, however, mostly consider our own hair for its social and aesthetic value, rather like the azure tail-feathers on a preening bird of paradise. Hair is a primary marker of our identities, the first feature we turn to in describing other humans. “Oh, she had brown curly hair,” we say. Or “He’s the ginger.” It’s also a sex symbol, creeping across our erogenous zones like an invitation and a veil. 

As such a subtle and manifold marker of identity, hair is fraught with meaning, a minefield of mixed messages. (Good on head! Bad on body!) Perhaps more than any other physical attribute, it’s something we can control, and control it we do. We tirelessly groom ourselves: cutting, shaving, waxing, threading, braiding, plucking, dyeing, bleaching, straightening, curling. We feel, and rightfully so, that hair can tell us a great deal about a stranger—sexual orientation, for instance, or mental health—and accordingly, we worry what our hair reveals about us. People with hair across a spectrum of thickness, colors, textures, lengths, and attitudes describe their hair as “difficult.” It’s a malleable feature most of us have to learn to live with and to cultivate, like our tempers and personalities. For even the tamest-maned among us, our hair feels unpredictable, impregnable, alien—unfair, even. Learning to bring our hair—and by extension, our image—under our control, and not the other way around, is a lifelong process. For much of our lives, we are at its mercy. 

For better or worse, hair is the stuff of selfhood. When we were children, my straight-haired sister, to torment me—and perhaps in genuine exasperation—called my uncombed curly mop “the rats’ nest.” As I grew older, I saw my curly hair, along with my buckteeth and my glasses, as a liability and a barrier between myself and beauty (and, therefore, between the boys I liked and me). In my eyes, my hair betrayed all my worst qualities—disorganized, awkward, unkempt, ample, kinky—and embodied all that was unseemly in a pubescent girl. It was only at the age of nineteen or twenty, when I began regularly ironing my hair into a blithe golden sheet, that I began to feel that I’d wrestled my sexuality and my identity under my own control. Like Jacob, I’d bested the Angel, and become blessed, and the world was delivered unto me. 

If hair is a crux of human identity, it is doubly so for women. As Celia Brayfield wrote in the 2004 Times article “A Lifestyle Haircut: When to say goodbye to your long tresses is a major decision”: “A woman’s long hair, after all, is the emblem of her femininity. More than that, it is a symbol of her sexuality, and the longer, thicker and more wanton the tresses, the more passionate the heart beneath them is assumed to be.” Hair is a marker of health and wealth too, and, vitally, of normalcy. Baldness, on the other hand, suggests all that is antithetical to healthy womanhood: masculinity, death, disease, indiscretion, plainness, and exposure. A bald woman is of the cancer ward or the concentration camp. The internet is replete with triumphant hair memes: “Life isn’t perfect but your hair can be.” “Give a girl the right haircut and she can conquer the world.” “Invest in your hair. It is the crown you never take off.” Two thousand years earlier, Paul wrote to the Corinthians along these same lines, “[I]f a woman has long hair, it is a glory to her, for her hair is given to her for a covering.”

Think of poor Jo March, stripped of her abundant brown hair, as her family cries, “‘Your hair! Your beautiful hair!’ ‘Oh, Jo, how could you? Your one beauty.’” Though she has sold her hair to help pay for her mother’s train ticket to visit her war-wounded father, Jo’s practical sacrifice is seen as extreme and nearly indecent. Her little sister Amy, “would as soon have thought of cutting off her head as her pretty hair.” Without her hair, what is Jo?

And yet, Jo isn’t so sorry to see her hair go: 

It will be good for my vanity, I was getting too proud of my wig. It will do my brains good to have that mop taken off. My head feels deliciously light and cool, and the barber said I could soon have a curly crop, which will be boyish, becoming, and easy to keep in order. I’m satisfied, so please take the money and let’s have supper.

Though she cries late at night, stunned and confused by her transformation, Jo experiences the loss as catharsis. She is lightened, unburdened, and unharnessed by the change; divested of a given identity she wore uneasily, and free to reinvent herself. 

Perhaps unsurprisingly, most experts agree that trichotillomania, like anorexia, occurs with higher incidence among women than men. The DSM-5 cites a prevalence ratio of ten-to-one. Of course, it is possible that even fewer men report their pulling than women do, for fear of being associated with what is often framed as a woman’s disorder, thereby distorting the numbers. But in its worst incidences, trichotillomania is hard to hide. And among the clinicians and scientists with whom I spoke, there was conviction that this gender-bias ratio was not a statistical error. Of the more than one hundred thousand Instagram posts with the hashtags #trich (40,900 as of this writing) or #trichotillomania (75,900), most feature women as well: Women bravely bearing their bald patches, women charting their regrowth in split-frames, women demonstrating methods to draw in eyebrows where none remain, women counting the days they’ve refrained from pulling, women documenting, with palpable anxiety, the results of a relapse. 

Like anorexia, the onset of trichotillomania usually coincides with puberty. Is there a time in an average girl’s life when she is more self-conscious than puberty, when the body sprouts and stretches and leaks in all sorts of unseemly ways, exposing the sexuality that, until now, had remained mercifully concealed? Even the healthiest and sanest among girls corral and control their hair as a way to forestall puberty’s inexorable march. At eleven, a classmate pulled me into a bathroom and asked if I’d grown pubic hair. I knew that she was looking to find her own experience reflected and validated in me, but I also knew that she might repeat my answer to our fellow classmates, and that to say yes was to expose myself to shame and sly glances. I said no. 

And again like anorexia, trichotillomania often begins as some version of a thing women are conditioned to do. Dieting and hair removal aren’t simply accepted in American culture, they are practically compulsory, two major rites of feminine passage. By twelve or thirteen, we were having shaving parties at summer camp, sitting in a large and noisy circle on the wood-slat floor, dunking our razors into plastic cups of water as we sang Alanis Morrisette. Those girls who didn’t shave their legs—because they didn’t have a razor, didn’t know how, or more poignantly, because their mothers didn’t want them to—were exposed to contempt.  

In childhood, trich often manifests as a benign activity that appears, at least, to be driven by boredom or curiosity rather than distress. As with thumb-sucking, hair-chewing, nose-picking, or any of the many idle physical destructions children indulge in, it would take a dedicated Freudian to unearth the latent neurosis. Moreover, hairpulling that begins in childhood often resolves without treatment. However, when hairpulling onsets at puberty, as it usually does, it manifests with a momentum and ferocity more obviously demonstrative of compulsive behavior—though trichotillomania is not a form of OCD. 

This second-stage intensity is probably a purely biological transformation—there is some research to suggest that hormone-level fluctuations occurring during the menstrual cycle accompany stronger urges to pull and diminished capacity to control those urges—and yet it is hard to discount its exact coincidence with the exceptional time in life when young women “discover” their hair as a complex social marker. Just as hair is appearing in new, uncomfortable places (it’s very common to pluck armpit and pubic hair), women are pressured or permitted to begin removing it. As one woman told me with a laugh, “I started tweezing my eyebrows and I never stopped.” 

If hairpulling sometimes begins as a form of aesthetic self-improvement, like so many of women’s actions upon their bodies, it quickly becomes something else. Psychologists make a useful distinction between two kinds of perceptions of one’s own behavior: Egosyntonic behavior feels right and good, natural even. Egodystonic behavior feels frustrating, repugnant, or even alien, as if possessing one’s body like the devil itself. Anorexia is stubbornly and chronically egosyntonic, in the sense that most genuinely believe that their anorexia is productive or necessary, making it extremely difficult to treat. But, even if the act of pulling itself often feels good, most pullers eventually want nothing more than the power and ability to stop. The matter goes beyond will. Some pull in their sleep, and wake up in a tangle of loose hairs. Others resist the urge for weeks, months, and then pluck their precious regrowth in a furious and unconscious flurry. Some pullers don’t realize they’re doing it until they’ve amassed a small pile around themselves, or until their scalp starts to bleed. These are the extremes. 

One uncomfortable, often unspoken truth of anorexia is that, even in its more extreme manifestations, the results are often pleasing to the eye. Moreover, a certain mythical status has been granted to the idea of the anorexic woman. Women who suffer from anorexia carry with them the achievement and armor of their own frailty; they embody the distinctively female weakness, both delicate and fierce, that so often inspires passion and infatuation in the breasts of men. In her essay “Grand Unified Theory of Female Pain,” Leslie Jamison writes that we “ascrib[e] eloquence to the starving body, a kind of lyric grace.” There is the potential for beauty and mythos in self-cutting as well: “I cut because my unhappiness felt nebulous and elusive and I thought it could perhaps hold the shape of a line across my ankle,” Jamison writes. 

Trichotillomania, on the other hand, has none of anorexia’s wan, violet glamour. There’s nothing sexy about a woman pulling out her hair. Unlike anorexia, which offers the possibility that a woman can, in dying, become the most graceful, purest version of herself, pulling is a slow walk toward the hideous and exposed. Indeed, trichotillomania, like obesity, is less likely to arouse pity than disgust. Perhaps herein lies the major difference between trich and anorexia: The former is indulgence, whereas the latter is abstention. Perhaps, too, we can better stomach a woman’s painful march toward beauty than her irrational stumble toward disfigurement. While anorexia has established a place in popular culture and a household-name status, trichotillomania remains virtually unknown. 

Even within the medical community, trich has been largely ignored. Most of what we know about the disorder is the work of a handful of dedicated clinicians and scientists. And, like those with trichotillomania, they too gather every year at the TLC conference. As a result, the conference was divided into two parallel worlds—that of the patient and that of the scientific researcher. Sessions were labeled accordingly: “Neurobiology of Trich” for “Researchers,” “Standing Up to the Trichster” for “Patients.”

Dr. Joseph Garner, an ebullient British zoologist and an associate professor of comparative medicine at Stanford University, led one session called “What Animal Behavior Can Tell Us About Trich.” He has studied fatal obsessive grooming behaviors in lab mice, in the hopes of curing the mice. As it turns out, captive mice pull out their hair, or the hair of their cage-mates, in much the same manner as humans, though in mice it’s called “barbering.” The barbering mice are majority female. Their barbering onsets at sexual maturity. Perhaps most strangely of all, many mice manipulate or play with the fur or whiskers they barber before discarding them, just as many humans run their plucked hairs across their lips. In short, the mice displayed all the idiosyncratic symptoms of trich. 

Garner tells me, “When I first got involved in trichotillomania, in 2004, the entire literature was a book and a stack of papers maybe an inch thick. There was literally nothing. Which is kind of astounding for a disorder that affects 3.5 percent of women. I think conservatively that puts trichotillomania in the top five most common disorders in women. And depending on how you count, you could make the case that it’s the third most common.” 

When I ask why there was so little attention given to trich, he explains that there was very little funding for research, and that the clinicians who did specialize in trich were too busy treating it to study it. He adds with a laugh, “You’re never going to become rich and famous working on trich.” 

Since then, and due largely to the efforts of the TLC Scientific Advisory Board, the literature has grown and deepened. Not least, Garner’s mice studies have offered valuable insights in miniature into the way trich functions in the brain. For one thing, by monitoring the brain activity of barbering mice with fMRI (real-time imaging of brain activity), Garner and his colleagues were able to confirm what scientists already believed: that trich functions on a different “level” in the brain than OCD. Whereas OCD is associated with impairment in the brain circuit that helps switch emotions, the barbering mice showed impairment in the circuit that helps switch goals (a striking, if simplified, distinction that also offers a deeper understanding of why some drugs—such as certain antidepressants—are not especially effective in treating trich). The mice are also the strongest evidence that the female bias in humans is real. And, intriguingly, Garner actually did cure the mice, with a gentle drug called N-Acetylcysteine or NAC, which is sometimes used to counteract acetaminophen overdoses, and which has been the most effective treatment of human trich to date. 

The mice aren’t alone. A whole host of mammals have been recorded pulling out their fur: primates, mink, musk oxen, guinea pigs, rabbits, sheep, dogs, and cats among them. And parrots are especially well-known for frantically plucking out their feathers in distress. I find myself humming Ella Fitzgerald: “Birds do it. Bees do it. Even educated fleas do it.”

In Animal Madness, Laurel Braitman writes about Little Joe, a gorilla at Boston’s Franklin Park Zoo who has spent most of his life trying to escape captivity (he has succeeded on occasion, and spent some time wandering the neighborhood). When he’s not trying to escape, Little Joe pulls out his hair, and sometimes eats it. Over at the Bronx Zoo, Braitman writes, 

[A] female gorilla named Kiojasha plucked herself so intensely that visitors asked about her. One of the docents said, “They couldn’t tell if she was a gorilla or not, she was so hairless. She honestly looked like a wizened old human woman. It was disturbing.”

The list goes on. But, as far as scientists have observed, this behavior doesn’t exist in wild mice or wild gorillas. It’s specifically found in captivity, where, it can fairly be assumed, the animals are miserable. 

What is the relationship between hairpulling and depression or distress? This was the question I found most difficult to untangle. Researchers and clinicians almost uniformly insisted that trichotillomania was a purely biological phenomenon, caused not by psychological distress but by any number of possible physiological mechanisms. And yet, to the lay observer, it seems intuitive that the disorder is connected to some latent unhappiness—after all, “tearing one’s hair out” is an old idiom for distress. Moreover, there is no lack of anecdotal evidence, like Nina’s story, that trichotillomania is often triggered by adolescent trauma or abuse. Indeed, one study of the disorder notes that, “a childhood history of psychosocial loss or stress has been associated with TTM [trichotillomania] onset, such as death/illness of a parent, parental divorce, alienation from friends, childhood illness/injury, or violence/abuse.” 

And yet, many people I spoke to at the conference—not researchers but patients—insisted that their trich was not simply a symptom of underlying depression. Any real distress, they countered, comes from the shame that accompanies the behavior, and not the other way around. And indeed, they all recalled an early memory of being shamed for pulling. One woman told me that an elementary school teacher called her disgusting in front of the class. A very young girl, who also has autism, said that she has been hit and kicked at school, and once locked in a closet. Her short hair gives her an elfin, androgynous look. Her classmates ask her, “What are you?” 

In the DSM-5, “clinically significant distress or impairment in social, occupational, or other important areas of functioning” is listed as one of the diagnostic criteria for trichotillomania. But what makes distress “clinically significant”? And, perhaps more saliently, how can we be sure that the distress or impairment is a function of the disorder itself, and not of its social reception? In other words, is it the pulling that causes distress, or is it the reaction to the pulling? 

One thing that struck me in my research was the frequency with which the people I met were ridiculed or punished for their pulling—not by teachers, bosses, classmates, and other outsiders, but by their own parents and lovers, the very people they might have turned to for unconditional support. The same woman who was humiliated by her teacher wrote in an essay that her parents routinely spanked her for pulling out her eyelashes. Later, after a bad episode, her mother “dragged me from my bedroom into her bedroom, but instead of hitting me, she went to the bedroom wall where my art was displayed and started to tear all of my artwork off the wall … During those days that passed, I remember praying to God to punish me for what I had done.”

On the Reddit/trichters thread, which is extensive, one user posed the question: “What’s the most insensitive thing someone’s said to you about your trich?” Many of the responses referenced family: “My Dad: ‘You used to be so beautiful before you started pulling out your hair.’” “My dad says the exact same thing. He also says ‘Do you really think (my boyfriend) is going to want you if you keep pulling your hair out?’” “My mother once told me ‘I think you do not realize how noticeable the bald spots are.’” “Had the pleasure of hearing my grandma say ‘She looks horrible, like a leukemia patient.’” 

On Instagram, a strikingly pretty nineteen-year-old named Lydian wrote, 

I have been bald or partially bald for the majority of my life, and have covered my scalp with wigs, scarves, beanies, and bandanas for years and years, hiding my bald spots from questioning gazes and concerned stares … I hated preparing myself for being in view 24/7. For swimming in public, sleepovers, or even after showering at night, I would feel the need to groom my hair to hide the spots. It was as though my hair was wearing me.

These women aren’t experiencing spontaneous upswellings of shame in the wake of their hairpulling. Rather, they are responding to a relentless and unambiguous message that the loss of their hair is nothing less than the loss of their selves and their social value. All of which leaves an awkward question hanging in the air: Would trich actually be a problem if people weren’t so intensely shamed for it? 

Dancing, weeping, and dragging their feet through the margins of Western literature is a long line of miserable women acting out their misery. Ophelia, surrounded by her own streaming tresses, sits beside the brook, weaving garlands and pulling flowers from the ground, “incapable of her own distress,” and then falls from a willow tree and drowns. Emma Bovary and Lily Bart careen through bouts of compulsive shopping, searching for the satisfaction that eludes them in their circumscribed lives, before falling deep into debt and dying by suicide. Miss Havisham shuts herself in among the moldering wreckage of her wedding and obsessively relives her heartbreak; in turn, young Estella compulsively punishes the people she loves. Jane Eyre, “delicate and aerial,” refuses to eat in front of Rochester. A New Yorker article on anorexia notes that, “In Goethe’s ‘Elective Affinities,’ the young Ottilie moves silently, with ‘perpetual exquisite motion,’ and practices ‘excessive abstemiousness in eating and drinking’; eventually, she dies.” 

It’s a cliché: Men get angry, women get sad. Men explode, women wane and waste away. Anorexia, bulimia, cutting, hairpulling, skin picking: These are women’s problems. Whereas men express their anger, women internalize it, acting out their emotions upon their bodies. 

What should we make of this odd triangle among womanhood, captivity, and compulsion? What unites these fictional women is an absence of agency in their own lives—they are not free to pursue the means necessary to live freely. Instead, they self-destruct. Today, women are discouraged, in myriad ways, but perhaps most of all through an implied failure of femininity, from expressing anger or discontent. Cutting, anorexia, and trichotillomania all seem, at least, to offer an alternative outlet for anger or discontent. Is it too much to say that when they pull and cut and diet, women, like the animals in the zoo, are reacting against their cage? 

There is, of course, an entire story behind this one, the story of my own pulling. Plucking at my hair on the Acela while I wonder how I can muster the courage to ask for interviews at the conference. Pulling out hairs in the taxi because I’m worried we’ve gotten on the wrong highway. Tweezing hairs on the rim of the hotel bathtub while I question if I’m connecting meaningfully with these women. If “how we spend our days is, of course, how we spend our lives,” as Annie Dillard once wrote, then pulling out my hair is my life. Less often quoted is Dillard’s later sentence: “The life of sensation is the life of greed; it requires more and more.” 

My father used to pull the hairs from his beard as he worked. I still see the little brown shards pooling on the papers below. Like Nina, I’ve found photographs of myself as a young child; in one, my hand hovers above my curls, my arm curved like a ballerina’s. Only years later—around ten or eleven, an age at which shame multiplies shame—do I remember consciously pulling my hair out, as I read in bed at night, struggling against sleep under the warm light of the lamp. The alien translucence of the bulb with its wet black tip, like a baby squid, never failed to shock—almost to appall—me. I would lay the hairs across the page of my book and draw pleasure from the clean dissonance of creamy paper and golden line. I let the root stick to the page and then experienced great pleasure from pulling the hair off later with a slight pop. It was simply something to do. 

Later, it became a process of aesthetic selection: I would search for the dark and kinky hairs among the smooth gold ones, feeling for EKG-like zigzag near the root. I felt, deep down, that hair by hair I was transforming myself into the person I hoped to become. 

I, too, weathered my parents’ divorce and an unfriendly high school and watched my habit worsen. My mother implored me to put my hand down during family dinners, as I tucked my chin and pulled with sullen insistence. My best friend in college cackled and called me, affectionately, his “witchy woman.” Men knew, men saw: The alacrity with which my lovers have noticed my habit startles me, where women I’ve known my whole life miss it. My first boyfriend took to drawing my hand down tenderly from my head. So did my second. 

The very mention of my pulling makes my mother feel guilty. Why? I ask. “If you hadn’t been under enormous stress,” she replies, “it wouldn’t have happened.” 

What happened though? Her implication is that my pulling is evidence that something went wrong with me, and threfore evidence of her failure as a mother. This annoys me: How can she know that I wouldn’t have started pulling in every possible world—in other words, that the potential for pulling isn’t simply in my nature? And yet, I can’t blame her for understanding my pulling as a sign of distress, when I’ve sought to understand it that way myself, time and time again. 

Now I’m not so sure. What looks like distress from one angle can look like hormonal imbalance from another. In my research, the distinction between the biological and the psychological became increasingly nebulous. In high school, I began cutting myself. Compared to trich, cutting seems like an obvious expression of distress. And certainly, at the time, I saw it that way—as a physical expression of the anguish I felt on a daily basis. But what I experienced so vividly at the time as depression to the point of malfunction now strikes me as the natural reaction of a young woman to an overwhelming surplus of new emotions with no outlet for them. They may have all been hormonal, which didn’t make them any less real. 

Pulling may have been activated by my unhappiness, but there is an innocent pleasure to the act. It has been a way for me to calm myself, to concentrate errant anxiety into a single act of tension. It holds the promise of a deep sense of well-being. Often, like a moving target, this well-being remains tauntingly out of reach as I pull, forever beyond the next hair; but in rare moments—the right hair at the right time—there is profound satisfaction. And at the best of times, a well-plucked hair, as it slides unwillingly from its follicle cocoon, is my lover and my best friend. 

Again and again at the conference, I heard the language of family invoked. “We are all a big family here at TLC!” announced one speaker. “We are a family, aren’t we?” said another. Like an AA meeting, there was a celebratory tenor to the community-speak that cut across the grain of affliction and disease, though at times they said, “Let’s beat this thing!” as though it were a cancer. Some of the women had been attending the conference for twelve years straight. They welcomed the “first-timers” with open arms. The speakers said, in so many ways: You were alone, but now you are with your people. 

While I was at the conference, this touchy-feely rhetoric annoyed me. I worried that if the many young people at the conference began to identify too strongly with their disorder, they would never escape it. I worried that young women, like Nina, would take so much comfort in their newfound solidarity that they would allow it to consume their lives. Indeed, the same bubbly teenager who gave the welcome speech later told a reporter from Buzzfeed, “I have a theory .… Once you’ve had trich for a long time, you get so far and deep into it that it’s, like, taken over you—you feel like there’s no help and that nothing you can do will help it. And you get brainwashed, in a way, into thinking that you like having it and that you don’t want to stop. So I’m kind of in that hole right now.” 

Nevertheless, despite my misgivings, it was only too clear what psychological benefits the community confers on its members. Attendee after attendee told me what a relief it was to discover that they were not alone in their habit, and that it was not their fault. I interviewed one woman with trich who also works at Hair Club, a company that offers various hair-loss solutions and maintains a presence at each TLC conference. On its website, Hair Club describes itself as “here to help boost your confidence and restore your identity by giving you back your hair. So you and everyone around you can experience the best possible you. The true you.” 

Sara is effusive and bright, with a steady and authoritative manner. It’s easy to imagine her in the dual role of counselor and saleswoman. Unlike the website, Sara doesn’t describe her work as a simple “here’s your hair back!” solution. Rather, she emphasizes the sense of overwhelming relief people feel upon learning the name of their disorder: “Some people are brought to tears that I even know the word. Full-grown adults come in who don’t even know that it has a name. They just tell me what they do, or they don’t want to tell me what they do. But I can tell, you know … And so when I say it, they are flooded with tears. Somebody’s heard of it, somebody knows that they are not a freak.” 

And indeed, it wasn’t until Sara was hired at Hair Club that she herself first heard the term trichotillomania. “Knowing that it had a name took my breath away. And talking to my fellow employees, some of whom are now my really close friends, [has] actually helped me get it under control. If I didn’t start working at Hair Club, I would probably be completely bald at this point.” 

None of that has to do with hair itself, but with community and social value. Perhaps this profound solidarity is the flip side of shame: As powerfully as social stigma can make one feel worthless, so can community make one feel valued. This is not just a matter of recognizing oneself in another, but rather of fundamentally redefining the terms of normalcy. 

In retrospect, I can see that my resistance to the groupthink of the conference sprang from a fear of being included in the group. Surely,I thought, I am not like these women. I have never experienced visible hair loss. I have never been shamed for my pulling. I have not integrated these actions into my identity. I don’t need to attend conferences or receive cognitive behavioral therapy. I have certainly never worn a wig. I felt like a marauder among the women and their affliction, and worse, I kept catching myself in the windows and mirrors of the hotel and rejoicing in the burnished flip of my hair, in my own normalcy. I felt together. And I felt that I had somehow earned that feeling, that the moderation of my own pulling was something I’d cultivated, not a stroke of random luck. I am simply not a person of great extremes, I told myself; a difference in degree is a difference in kind

And yet—the doctors and psychotherapists describing their patients’ symptoms described me. It was almost uncanny, the specificity with which they detailed my own careless pulling. Like their patients, I’m prone to tug on my hairs while I work or study. Like them, I use my pulling as a stopper to boredom, a way to focus my attention or wandering thoughts. And indeed, my pulling grows worse when I’m anxious. I pull at my hair when I’m stuck in traffic. When I’m on a plane. When I’m reading. When I’m thinking hard. When I’m feeling uncomfortable around friends or family. Like blinking, I can hardly say when I’m doing it and when I’m not. It does not occur to me to try to stop, any more than I might try to stop breathing. I couldn’t tell you how many times a day I reach for my hair—a hundred? A thousand? I only know that I have to, and others don’t. 

In denying an association between these women and myself, I was attempting to claim a fantastical agency on my own behalf. I am no more in control of my behavior than they are. The worst moment came when one of my interviewees, a kind and thoughtful twenty-two-year-old, asked me about my own story. I tried to tell her, fudging the details a bit: As I got older, I explained, things got easier. She asked me with genuine excitement: “So you’re actually cured?” I felt terrible, like I’d somehow bamboozled her. Far from cured, I’ve never even attempted to stop. I still do it daily, hourly, in coffee shops, and in bed. I’m doing it right now. 

Of course, my worry that these young women will never “get better” and my certainty that I am not like them are ultimately one and the same: an attempt to cleave the world of the healthy from the world of the afflicted. Is a difference in degree a difference in kind? When does a bad habit become a disorder? Does it matter? Perhaps our desire to pathologize—to demarcate and define what is and what is not mental illness and duly record it in the DSM—is a talismanic gesture, performed to keep the specter of illness at bay. 

Perhaps trich, like all forms of masochism, is an incarnation of what Freud called the death drive: our desperate attempt to disrupt the relentless forward movement of life. In heartbreak, we often bitterly rail against the resilience of our own hearts; we don’t want to move on, because to move on is to betray the seemingly eternal significance of our love. But eventually we do move on. We forget, because we must forget in order to live. To those in great pain, the human tendency to heal is a mixed blessing. The durability of our bodies is at times an insult to the fragility of our souls. 

One of hair’s most notable qualities is its stubborn resilience. It doesn’t stop growing. For many of us, this stubbornness is a Sisyphean annoyance. How many times must we wax? Shave? Epilate? We’ve invented myriad technologies to strangle hair at the root, to banish it forever. But hair’s resilience is a miracle. However much we tear it out of our skin, it creeps back, like Whitman’s leaves of grass, of which “the smallest sprout shows there is really no death/ And if ever there was it led forward life.” Hair is a reminder that what feels like the end is rarely the end. Life goes on. 

For some people with trich, the only solution is to remove temptation itself: to continually shave one’s head. This action may be tantamount to escaping the cage. In shaving her head, a woman is refusing to accept womanhood on its prescribed terms. The same young woman who lamented that her hair was wearing her went and shaved it off. She said, “My long hair has become a burdensome obligation to fulfill the expectations of others.” I no longer see shaving one’s head as “giving up,” but as an act of profound resistance. I salute these women. 

About a year before the conference, Nina fell into a deep depression, not unlike the episode she experienced during her junior year of high school. She stopped going to class. She told me, “There was a week where it got to the point where I couldn’t make myself eat,” she said. “Or go to the bathroom. Or get out of bed. Or talk to people. I remember having open wounds and sores on my face [from picking it], which prevented me from going to class. I knew this was serious.” 

She went to her parents’ house (though they have been separated for years, Nina’s parents still live together. “It’s a constant war zone,” she said). Nina’s mom took her to her therapist who told her that unless Nina could pull herself out of the catatonic state, she would have to go to a full-time care facility or “partial”—a treatment facility where the patients go home at night. Nina chose partial. “I was there for five days,” she said. “And funnily enough, I never brought up the trich while I was there. A lot of people were depressives or had bipolar disorder so I just didn’t think it was high on the priority list.” 

She felt that she came out stronger, or tougher, at least. “It made me more mature. I saw people who got stuck in the system—not that people don’t have real struggles or don’t really need to be in those facilities—but I found a lot of people who kept getting cycled through. I didn’t want to be that.” 

When I met Nina, she was in another relationship and he knew about the pulling, but they didn’t talk about it much. Though she was relieved that he knew, she worried that the refuge of his knowledge left her disarmed and vulnerable. “Because of the way I feel about myself, I feel like I owe him for still liking me.” She did not let him touch her hair. 

I asked Nina what it might mean to recover and she laughed. “The number one question I get from therapists is: ‘Do you want to stop?’ Which pisses me off. Who the hell would not want to stop? Obviously I have this desire to kill it with fire. But I think what they mean by wanting to stop is—willing to be in that discomfort zone of not using it as a crutch. And yeah, that would be great, but right now for me recovery would mean … ” She paused. “Being able to wear my hair down. Maybe having a part. If I could just get to that milestone, it might be a little easier to see the light. I’m pretty good at hiding it. But it’s never not going to be a part of my life. I hate that.” 


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