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Mental health

Striving for Perfection

Far more girls and young women today are going through mental health crises, says child and adolescent psychologist Dagmar Pauli. In our interview, she talks about the influence of school and social media, boys with gaming addictions, and the problems facing transgender youth.
Interview: Roger Nickl, Translation: Karen Oettli-Geddes
The demand for perfection is particularly pronounced among young girls.
The demand for perfection is particularly pronounced among young girls, partly because of false role models on social media. (Image: iStock, Georgijevic)

Dagmar Pauli, you treat girls, boys and transgender adolescents at the University Hospital of Psychiatry and conduct research on mental disorders in children and adolescents. How gender-specific are these disorders?

Dagmar Pauli: In child and adolescent psychiatry, it’s long been known that girls and boys differ in terms of the number of mental health problems they have and the form they take. For example, conditions like ADHD and autism are much more common among males, while eating disorders and depression are more prevalent in females. At the hospital, we’re noticing that far more girls and young women today are going through mental health crises, with symptoms such as depression, self-harming, and eating and anxiety disorders.

Do you know the reasons?

Pauli: One reason is that children and young people in general are inundated with all kinds of information, stimulation and expectations – at school, for example, and on social media. Not everyone can cope with this. Perhaps girls are more vulnerable in this respect, because they respond more sensitively to images and their social environment. Young girls in our clientele often set themselves very high perfection standards, not least because of the role models they see on social media. Social media is also where unsatisfactory coping strategies are spread. Today, even children as young as 11 and 12 say: “I felt so bad and was bullied, so I harmed myself. I was triggered.” They generally pick up expressions like this online. We’re currently experiencing a crisis that’s disproportionately affecting girls and young women who are simply overwhelmed by expectations.

Where do these perfection standards come from? 

Pauli: Genetic predispositions have something to do with it, as certain personality traits are passed on in families regardless of gender. But how girls are socialized also plays a role. Studies show that girls and boys are treated very differently, starting in infancy and young childhood. Those socialized as female often feel compelled to meet all the expectations placed on them – like doing well at school or maintaining an idealized image on social media. This can all become too much for them and lead to mental illness.

What are the challenges for boys?

Pauli: They face problems like gaming addiction, for example, which has grown extensively in the last 10 to 15 years. Teenagers feel comfortable in this online gaming environment, surrounded by cool avatars and lots of friends, and where they can be successful. Especially if they struggle to find success in real-life settings, the online world can be a true form of escape. Boys are more susceptible to this escapism than girls. In the online environment, they can fulfil their needs for recognition or power – in ways that are impossible in reality – and experience the status they crave: if they’re no good at sport, for example, or don’t fit in with their peer group. However, when the disparity between the online world and reality becomes too stark, addiction can result.


Those socialized as female often feel compelled to meet all the expectations placed on them – like doing well at school or maintaining an idealized image on social media. This can all become too much for them and lead to mental illness.

Dagmar Pauli
Child and adolescent psychiatrist

You also offer transgender counselling. What insights have you gained from your work there?

Pauli: The problems experienced by adolescents are much more marked in the transgender group. Seventy percent of our transgender patients are depressed and display symptoms like suicidal tendencies, self-harming and anxiety disorders. There are a number of reasons for this: transgender adolescents still have difficulties with finding acceptance, coming out to their family, and at school. These are major hurdles to overcome. Studies have shown that when parents are supportive of their children’s social transition – that is, life in their chosen gender – the children are mentally much more robust. Social recognition plays a pivotal role in their psychological well-being. In addition, many transgender youths suffer from body dysphoria: they feel that their body doesn’t match with their identity. Patience is key here, as irreversible medical interventions need to be approached with caution at this age. It’s evident that gender-specific research in this field is needed: when it comes to both diagnosis and therapy, major differences exist in the treatment of transgender male, transgender female and non-binary adolescents.

We know that it’s mostly girls who are more susceptible to eating disorders, which is why the problem often goes undetected in boys.

Dagmar Pauli
Child and adolescent psychiatrist

Mental health issues present in different ways according to gender. Are there any gender-based treatment approaches in child and adolescent psychiatry?

Pauli: No, so far hardly any at all. However, I believe that doctors and psychologists intuitively tailor their approach when treating depressed teenagers, depending on whether they’re male, female or non-binary. In other words, we apply our knowledge of gender-specific characteristics. We know, for example, that it’s easier to talk to girls about feelings or things that could be associated with shame. With boys, on the other hand, we may handle these topics more cautiously and give them more opportunities to first talk about their behavior before delving deeper. Or we try to look behind the façade, in the assumption that there might be more to it when a boy appears to be dissatisfied and displays aggressive and sullen behavior. This could also be indications of depression. But, as I said, these are intuitive assumptions. The topic has not been adequately researched and very little has been translated into specific gender-specific therapy approaches.

How can a gender-medical perspective contribute to improving diagnosis and therapy in child and adolescent psychiatry?

Pauli: I’m hoping that it will enable us to develop more individualized approaches to diagnosis and therapy. We know, for example, that it’s mostly girls who are more susceptible to eating disorders, which is why the problem often goes undetected in boys, sometimes because their symptoms are different. Initially, a problem may be interpreted as physical, with countless investigations carried out before ultimately concluding that the boy has an eating disorder. Another example is autism: we know that girls normally display different symptoms than boys. Most autism studies are based on boys because the problem is more common among males. Accordingly, when the symptoms were originally defined, they were described in terms relating to boys. This has led to girls on the autism spectrum frequently being underdiagnosed – because they don’t display the symptoms typical of boys. A gender-medical perspective could therefore improve diagnostics – and be an important factor in therapy, too. In the future, we should examine which treatment approaches are best applicable to each gender.

What should gender-specific psychotherapies entail in the future? 

Pauli: We should develop diagnostic tools capable of recognizing disease subtypes – although they wouldn’t specifically need to be sex-specific. For example, when diagnosing depression in adolescents, we could differentiate between different phenotypes and then tailor the therapeutic approaches accordingly. We could separate the irritable, sullen, quick-tempered type from the self-harming, anxious, introverted and inhibited type. Of course, we could assign these types to the traditional genders, but we wouldn’t have to necessarily stipulate that boys should be treated one way and girls quite differently. After all, individual cases show that this often isn’t true. With regard to behavior, preferences, and psychological symptoms, there are atypical boys and girls who deviate from traditional gender norms – even when they’re not non-binary or transgender. This is why, in both diagnosis and treatment, we should start describing patient groups in much greater detail. This would constitute precision medicine that incorporates gender-specific aspects with all its nuances.

This article is from the current UZH Magazin "Gesunde Frauen und Männer".

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