Alex was born with male anatomy. She grew up knowing she was “supposed to be a boy,” but as a young child, she never felt like that gender fit. When she hit puberty, she became anxious and depressed about how her body was becoming more masculine. She started dressing in gender-neutral clothing and wearing makeup, and was happy when strangers perceived her as a girl.  

In ninth grade, she took on a female name and came out as transgender to her friends at boarding school. She started going to a therapist, who diagnosed her with gender dysphoria. At 15, she asked to transition, and her parents, though reluctant, brought her to the Boston Children’s Hospital Gender Management Service, where she started a puberty-blocking medication. She was prescribed estrogen pills about a year later to help her go through female puberty.

After four months on the hormonal medications, she decided she did not identify as female but rather as gender nonbinary (neither male nor female) and would use the gender-neutral pronouns they, them, and theirs. At this point, they also stopped the medications and went through male puberty.

Alex, whose case I described recently in the journal JAMA Pediatrics with two other Harvard physicians, has no regrets about taking the hormones. Though the hormones left Alex with some cosmetic changes — redistribution of body hair and fat — Alex says they were necessary to fully solidify their gender identity. (Their name was changed to protect their privacy.)

As a doctor and researcher who studies the mental health of transgender youth, I was alarmed to learn that the Trump administration is planning to invalidate the experiences of transgender people by defining gender based on a person’s genitalia at birth. This comes in the midst of a flurry of media stories about transgender youth who choose to stop hormone therapies, ranging from a cover story in the Atlantic to more heavy-handed pieces from conservative writers and pundits who have painted a picture of crazed liberal doctors irreversibly “mutilating” the bodies of confused children.

The reality could not be further from the truth.

The vast majority of transgender kids who begin hormonal treatments do not change their minds about medically transitioning. For the very small percentage who do, like Alex, this isn’t the horrible outcome that conservative media outlets lead people to believe. Sometimes “de-transitioning” is just part of a person’s healthy psychological development.

How likely is your transgender child to change their mind?

Before parents let their children start hormone therapies, they often want to know how likely their child is to later change their mind about transitioning. The answer depends on if their child has hit puberty.

For adolescents who have reached the earliest stages of puberty, the odds are very low. A large study of transgender adolescents from the Netherlands found that only 1.9 percent of those who hit puberty and start puberty blockers decide to stop treatment like Alex did.

There is more debate around how likely prepubescent children are to later not identify as transgender. For this reason, they are not offered hormone therapies. They also, by definition, have not yet started puberty, and thus there is no puberty to block and no need for hormone therapy.

Parents should not panic about reversible interventions for transgender youth

It’s possible that many prepubescent transgender children will, in fact, change their minds about transitioning medically. We don’t have great research to know.

Luckily, the interventions that doctors would recommend for kids this young are completely safe and reversible. Medical guidelines advise that prepubescent children not be offered any hormonal interventions. What a psychologist or psychiatrist might recommend is allowing the child to “socially transition” if the child so desires.

A social transition may involve the child taking on a new name or new pronouns, or wearing stereotypical gendered clothing. Mostly, it means not placing restrictions on how your child wants to express their gender. A social transition is, of course, completely reversible, and not inherently dangerous.

Early studies have shown that transgender youth who are allowed to socially transition have mental health nearly indistinguishable from their cisgender peers (a stark contrast to past studies of transgender youth who weren’t allowed to socially transition who had high levels of anxiety and depression). If a child stops identifying as transgender at this stage, they simply go back to the pronouns, dress, etc. of their gender assigned at birth.

Again, if a child has hit puberty and identifies as transgender, they are much less likely to later stop identifying as transgender. At this stage, a doctor may offer a “puberty blocker.” These medications temporarily stop puberty from progressing, allowing the adolescent more time to explore and understand their gender identity. (It’s very helpful for the adolescent to be in psychotherapy during this time to navigate these decisions.)

Puberty blockers like Lupron are approved by the Food and Drug Administration and have been used for decades for precocious puberty, a condition in which very young children go through puberty too early. The only significant side effect is that the adolescent may fall behind on bone density. For this reason, doctors will regularly check bone density while the patient is on the medication. If the medication is stopped, bone density catches up to normal after a few years as the child goes through the puberty of their gender assigned at birth.  

Alternatively, if an adolescent continues to identify as transgender and starts on gender-affirming hormones like estrogen or testosterone down the line, this will also catch them up on bone density. The great thing about puberty blockers is that if you stop them, puberty will progress as if the medication were never started. Parents can think of a puberty blocker as buying their children more time to figure out their gender identity without going through puberty.

The potential mental health benefits of gender-affirming hormones usually outweigh the risks

Gender-affirming hormones like estrogen and testosterone are bigger decisions. They are generally not prescribed until a patient is 16 (though they can be prescribed as early as 14 in select clear-cut cases). They will cause body changes that are not easily reversed, like body fat redistribution and changes in body hair. Adolescents should be counseled extensively before starting these medications.

Parents should also remember, however, that these changes are mostly cosmetic. The potential benefits from gender-affirming hormones (improved mental health) will usually outweigh the low risk of an adolescent later changing their mind and regretting cosmetic changes. This risk-benefit analysis should be carefully discussed in therapy before these drugs are started.

Surgery is, of course, irreversible and requires serious thought. Big surgeries like phalloplasty (construction of a penis) and vaginoplasty (construction of a vagina) are not offered until patients have reached adulthood.

Every decision in medicine involves weighing risks and benefits. Lipitor, a medicine doctors use to prevent stroke, also increases the risk of rhabdomyolysis, a condition of muscle breakdown that can damage the kidneys. However, the potential benefit of preventing stroke far outweighs the potential risk of this unlikely event.

The same is true for transgender youth and gender-affirming care. Will a small number change their minds about medically transitioning? Yes. Does this mean we should withhold a treatment that has a high likelihood to provide a big mental health benefit? No.

Jack Turban is a resident physician in child and adolescent psychiatry at Massachusetts General Hospital and McLean Hospital. His research focuses on the mental health of transgender and gender diverse youth.

When I open the Grindr app on my smartphone, I see there’s a 26-year-old man with tanned abs just 200 feet away. He’s called “looking4now,” and his profile explains that he wants sex at his place as soon as possible.

Scrolling down, I find 100 similar profiles within a one-mile radius of my apartment in Boston. I can filter them by body type, sexual position (top, bottom, or versatile), and HIV status.

As a gay psychiatrist who studies gender and sexuality, I’m thrilled with the huge strides we’ve made over the past decade to bring gay relationships into the mainstream. The Supreme Court ruled that same-sex marriage is a constitutional right. Today in Boston, two men can walk down the street holding hands without consequence.

But I’m worried by the rise of the underground digital bathhouse. Apps like Grindr, with 3 million daily active users, and others like Scruff and Jack’d, are designed to help gay men solicit sex, often anonymously, online. I am all for sexual liberation, but I can’t stop wondering if these apps also have a negative effect on gay men’s mental health.

Since there’s little published research on the men using Grindr, I decided to conduct an informal survey and ask men why they’re on the app so much and how it’s affecting their relationships and mental health. I created a profile identifying myself as a medical writer looking to talk to men about their experiences. I received about 50 responses (including propositions).

It’s a small sample size, but enough to give us some clues about how Grindr is affecting gay men. And it doesn’t look good.

Apps like Grindr are designed to make finding sex easy. And that can make them hard to stop using.

The most common reason users gave for going on the app is that sex feels great and Grindr makes it accessible, right at your fingertips. The screen full of half-naked men excites users. With a few clicks, there’s a possibility of meeting a sexual partner within the hour.

Neuroscientists have shown that orgasm causes activation of pleasure areas of the brain like the ventral tegmental area while deactivating areas involved with self-control. And these patterns of activation in men are strikingly similar to what researchers see in the brain of individuals using heroin or cocaine. So when a neutral action (clicking on Grindr) is paired with a pleasurable response in the brain (orgasm), humans learn to do that action over and over again.

This can be a normal pleasure response or it could be a setup for addiction, depending on the situation and individual.

Grindr, intentionally or not, also leverages a psychological concept called variable ratio reinforcement, in which rewards for clicking come at unpredictable intervals. You may find a hookup immediately, or you may be on your phone for hours before you find one.

Variable ratio reinforcement is one of the most effective ways to reinforce behavior, and it makes stopping that behavior extremely difficult. Slot machines are a classic example. Because gamblers never know when the next payout will come, they can’t stop pulling the handle. They hold out hope that the next pull will give them the pleasurable sound of coins clanking against a metal bin, and they end up pulling for hours.

Now imagine a slot machine that rewards you with an orgasm at unpredictable intervals. This is potentially a powerful recipe for addiction and may explain why one user I spoke with stays on Grindr for up to 10 hours at a time, hoping to find the perfect partner for casual sex.

The phrase “addiction” continues to be controversial when it comes to sex and technology, But as John Pachankis, an LGBTQ mental health expert at the Yale School of Public Health, described the impact of Grindr to me: “I don’t know if it’s an ‘addiction,’ but I know it causes a lot of distress.”

For now, it’s hard to know just how many Grindr users feel their use of the app is problematic. Early research on app use and health has focused only on sexually transmitted infections, for instance, rates of HIV among Grindr users, using Grindr to get people tested for STIs, etc.

Just last week, Grindr announced that it will start sending users HIV testing reminders and the addresses of local testing sites (on an opt-in basis). In less pleasant news, BuzzFeed revealed on Monday that Grindr has also been sharing the HIV status of its users with third-party companies. (The company later said it would stop sharing the information.)

Though there is this new attention to sexual health, both Grindr and the research community have been silent on mental health. Yet since 2007, more gay men have died from suicide than from HIV.

This suggests it’s time we start thinking about Grindr’s health effects more broadly. Other dating apps, like Tinder, for example, are now the subject of early research looking at mental health implications. It’s time to do the same for gay hookup apps.

Grindr may provide men with some relief from their anxiety and depression. But it’s temporary.

For some users I talked to, the allure of Grindr was not just the rush to feel good. It was to stop feeling bad. Users told me they log on when they feel sad, anxious, or lonely. Grindr can make those feelings go away. The attention and potential for sex distract from painful emotions.

A staggering number of gay men suffer from depression, with some estimates as high as 50 percent. Because gay men’s anxiety and depression often stem from childhood rejection for being gay, messages of affirmation from other gay men are particularly appealing. Unfortunately, these messages are typically only skin-deep: “Hey man, cute pic. Looking to ****?”

A recent survey of 200,000 iPhone users by Time Well Spent, a nonprofit focused on the digital attention crisis, showed that 77 percent of Grindr users felt regret after using the app.

The users I interviewed told me that when they closed their phones and reflected on the shallow conversations and sexually explicit pictures they sent, they felt more depressed, more anxious, and even more isolated. Some experience overwhelming guilt following a sexual encounter in which no words are spoken. After the orgasm, the partner may walk out the door with little more than a “thanks.”

And yet they keep coming back for that temporary emotional relief. One user told me that he feels so bad after a hookup that he jumps right back on the app, continuing the cycle until he is so tired he falls asleep. Every once in a while, he deletes the app, but he finds himself downloading it the next time he feels rejected or alone.

“We see patients like this almost every day,” Pachankis told me. “Apps like Grindr are often both a cause and a consequence of gay and bisexual men’s disproportionally poorer mental health. It’s a truly vicious cycle.”

Not all Grindr users are addicted and depressed, of course. Some users I interacted with seem to use Grindr in a healthy, positive way. One man I interviewed met his fiancé there; they are excitedly planning their wedding. Some I spoke with said they use the app for sex but haven’t suffered any negative consequences and have control over their use.

Using Grindr may keep men from finding lasting relationships

Why do so many of these men turn to Grindr to begin with? Perhaps Grindr’s popularity is a sign we haven’t made as much social progress as we think for same-sex relationships. The general population seems comfortable with the idea of gay marriage, but it’s still difficult for a gay man to find a partner.

One 23-year-old user told me that the only places he can find gay men are clubs and Grindr, and both are hypersexualized. The cultures of both intimidate him. According to Pachankis, gay culture is often “status-focused, competitive, hierarchical, and exclusionary.” He explains that these traits are common among men generally, but in the gay community, they become amplified in a group that “both socializes and sexualizes together.”

The 23-year-old is afraid of rejection, and Grindr shields him from the pain of in-person turndowns. “My framework now is sex first. I don’t know how to date people in person.”

His relationships, he says, start with casual sex on Grindr. They first meet at 2 am for a hookup. He’ll try to schedule the next sex date a little earlier, maybe 11 pm. Then the next step may be drinks.

But this sex-first approach hasn’t led to lasting relationships for the men I interviewed and is affecting their self-worth and identity. “My self-esteem now is all about my sexual ability,” the 23-year-old said. “I don’t feel confident about myself as a partner in any other way.”

Another user told me he downloaded the app hoping to find a husband. Now he says that when he and a boyfriend (he’s gone through several) fight, his natural response is to open Grindr to “find an alternative” instead of working through problems. He can’t maintain a monogamous relationship because he is constantly cheating.

There may be ways to treat men with problematic Grindr use

The mental health professionals I spoke to are seeing problematic Grindr use in their clinics. And there is little published guidance on how to help those who are struggling.

Doctors I spoke to say the best available tools for treating problematic Grindr use are the ones they use in general sex addiction treatment. Citalopram, a common antidepressant, was shown in one small study to be helpful with sex addiction in gay men. Naltrexone, a drug commonly used for other compulsive behaviors, may work as well.

For more extreme cases, patients could request hormonal implants that turn off testosterone signaling, making sexual cravings less intense. However, even these treatments have modest empirical support at best, and none have been studied for hookup app use specifically.

Dr. Shane Kraus, the director of the behavioral addictions clinic at Bedford Veterans Hospital and an assistant professor of psychiatry at the University of Massachusetts Medical School, says the most promising treatment for problematic Grindr use is likely talk therapy techniques like cognitive behavioral therapy (CBT). CBT can teach patients to engage in other behaviors that are more productive (though often more difficult and time-consuming than Grindr) to help them feel loved or supported.

Another psychotherapeutic technique known as acceptance and commitment therapy (ACT) can help teach patients how to better tolerate the feeling of being alone without logging on to Grindr.

The dynamics of Grindr, though, are complicated, and it can take time to work through all the angles. Are you self-soothing anxiety? Are you addicted to sex? Have you lost interest in your monogamous relationship? Do you think you can’t attain love, so you’re settling for hookups? Did your parents tell you being gay is wrong and you’re searching for acceptance? Ultimately, Kraus explains that therapy can help clarify these kinds of thoughts and feelings, and lead to insights that bring about a healthy change.

He also believes it’s only a matter of time before states and the federal government sponsor research exploring Grindr use and mental health. Grindr did not respond to our request for comment on this piece. But if future data supports what I suspect about the link between Grindr and mental health problems, even small interventions like advertising mental health resources on the app may help to address these users’ suffering.

As we continue to fight to bring gay relationships into the mainstream, we need to keep an eye on Grindr and how it both reflects and affects gay culture. The bathhouse is still around. It’s now open 24/7, accessible from your living room.

Jack Turban is a physician and medical writer at Harvard Medical School, where he researches gender and sexuality. His writing has appeared in the New York Times, Scientific American, and Psychology Today, among other publications. Find him on Twitter at @jack_turban.