top of page
Marble Surface
  • Faith Kuzma

Bots who Nudge with Trans Messaging

Updated: Nov 22, 2023

By Faith Kuzma

Trans Medicine Tracks Talk of Body-Related Distress

In August 2022, a Danish longitudinal study using some of the most robust data tracking available showed that taking hormones dramatically increases the risk of heart disease. Nevertheless, according to a more recent August 2023 study, the number of youth seeking trans medicine has spiked. Trans surgeries in the States tripled for the under 40 crowd over just three years, according to the study author, Jason D. Wright, who urged more research to understand why. While Wright and others lament the lack of available care, a more immediate cause is social media, with its star surgeons, trans influencers, and automated bots.

What are bots and how might they shill for big medicine? A chatbot is an automated program set up to simulate a human interlocutor to respond to questions and provide information. However, bots are advancing far beyond this initial formula-driven model of automated replies. Even the sophisticated Alexa — provider of Internet data — is overshadowed now by chatbots utilising machine learning to converse more naturally with humans. "That does not compute" modes are being rewired to accommodate and adapt to novel context cues along lines more closely resembling human dialogue and interaction. Medical providers already deploy these more polished chatbots primarily to direct inquiries but also for initial screening.

Although Canadians are generally aware social media bots spam social media threads taking a virtual wrecking ball to civic discourse, they are less aware of their wide-scale applications in influencer marketing. Indeed, embedded with increasing sophistication, bots can be difficult to spot, mixing with genuine comments to steer online self-help groups organised around identity. In particular, bot-tracking of those exploring “gender issues” is commonplace, according to Michelle Santiago Cortés, who writes: “We say things like 'TikTok’s algorithm knew I was bi before I did' and are so impressed with its perceived ability to ‘know us’...Our algorithmically orchestrated encounters with people…on social media start to feel preordained, as if the fact that the algorithm put something on our path Means Something.” As this comment suggests, bots are ubiquitous, particularly because both medical institutions and the administrative state have embraced aspects of nudge theory delivered in the form of bot messaging.

The term nudge — formulated by Cass Sunstein as nudge theory — describes a presentation of choice architecture-such as using default opt-ins where a passive decision is automated in the interest of an undisclosed but obvious agenda-to direct decisions while minimally safeguarding free choice. Although presenting as simply educational, nudges are not neutral and in fact operate at the subliminal level and are classified as soft behavioural “strategies.” For instance, research identifies nudges that “expose the participant to certain cues (e.g., words, smells, or images) in order to alter behavior subliminally. These strategies work by activating representations or associations in memory just before carrying out the target behaviour.” In the social media context, it is especially relevant that nudges involve setting norms and suggesting action steps that follow.

Health Messaging on Social Media Acts As Nudge To Take Next Step

But do health authorities use bot messaging to affect behaviour? We know that health authorities ostensibly fight “misinformation.” On this basis, doctors may also feel compelled to engage in social media messaging, and while some present their services without much fanfare, others adopt the lingo and the glamour shot results echoing the social media presentation of trans influencers.

In fact, Ontario’s McLean clinic has become an influencer clinic with a large following on Instagram. In a fascinating analysis of the carnival-like festivity of these stakeholder clinicians, Canadian columnist Barbara Kay describes their general “dumbing down” of risky surgical procedures in order to make the whole procedure “fun.” The surgeons perpetually euphemise invasive surgeries, skip over the need for any psychological evaluations or even surgical second opinions, and above all never ever second guess a patient’s self-diagnosis. Taken in sum, this affirming model that never questions anything, even the age of their patients, serves as the very yardstick for medical misinformation.

And misinformation comes through online peer consultations. Youth reassure one another all their distress will be relieved by identifying as trans. As Laurel Duggan writes for Daily Caller, "Teens offer advice to each other about signs they might be trans, which include disliking their bodies, disliking puberty, having a short haircut, not wanting to wear 'girly' clothes, not liking one’s birth name or taking an interest in people of the opposite sex." In other words, gender nonconformity what once was taken as living life in modern times is taken as absolute proof.

This kind of peer-diagnosis is problematic. And within the industry, the head of World Professional Association for Transgender Health (WPATH), Dr. Marci Bowers, further questions the sensational social media sharing of private details which include partially nude patient photos posted by plastic surgeons. In practice, however, while acknowledging legitimate concerns that social media-referred patients are not fully or reliably informed about the risks of “trans- affirming” medicine, these surgeons anticipate “a greater presence on social media in the future.”

That greater presence is because as a “top performer,” trans medicine has a fiduciary responsibility to deliver on projected profits. In Canada, both private and public sector gender clinics can earn a lot more income when a mastectomy is part of trans-medical procedures. What has motivated the new female market for these surgeries?

Social media and online communities are a major major inception point, according to the landmark study by physician-scientist Lisa Littman, who identified a demographic shift toward a younger, predominantly female cohort for double mastectomies. Trans-medicine providers have thus been able to overcome major ethical boundaries to directly market services to youth by seizing territory on basically unregulated social media accounts. Given the billionaire investment on the front end funding new gender clinics, this is perhaps unsurprising. Trans-medicine promises lifelong patients and other, more immediate, payoffs (1). It also serves as an on ramp to trans-medicine. Indeed, therapists acknowledge medical misinformation is rampant on social media. Significantly, however, their analysis does not extend to the most profitable sector of gender misinformation. In the Wild West of influencer media, distress gets amplified by reciprocal sharing till it’s reconfigured as identity-destabilising dysphoria. Abigail Shrier’s detailed description of the new social-media cohort seeking trans-medicine in her book Irreversible Damages led clinical psychologist Erica Anderson to resign from the board of US Professional Association for Transgender Health (USPATH), troubled by youth “seizing upon an identity that to them may explain their distress.”

So while societal forces play a major role, it’s not in the simplistic way implied by those who explain away the rush to clinics as a result simply of a new era of acceptance. For one thing, distress appears to get echoed or reciprocated on social media. Therapist Stella O’Malley has observed “excessive rumination, repetitive discussion of problems, [and] positive reinforcement of similarities” as elements of a social contagion. Distress is reprocessed as dysphoria.

Emulating the attitudes of social media influencers is the first step in the transmission, but trans messaging is ubiquitous online, and it can look an awful lot like suggestive sale. For instance, wearing a binder for a week can be encouraged to calm anxiety. Later, trans-medicine enters the person’s choice horizon. Unsurprisingly, dysphoria is a term increasingly coming under scrutiny, and its latest replacement, “gender incongruence,” continues to mask other problems. This is because humans see what we focus on, and regular trans media use can intensify body hatred.

Trans-messaging, precisely timed, can be very compelling to those experiencing unrelieved distress. Compounded by online activity, itself a well-known stressor, dysphoria is part of the magic of the computer age. Over all, “social media addiction [is] significantly and positively correlated with depression, anxiety, and stress.What’s more magical is the blurring of reality and social influence, as Internet activity becomes “meshed with our offline sociality” in a way that shapes self-concept.(2) Trans-medicine is the corridor drawing the online identity into the real world.

Bot Messaging Acts as Nudge toward Trans-Medicine

Social media bots create a prolific market for trans-medicine. Tumblr* posts have long been linked to hospital websites because its hallmark is comparison making within a space devoted to expressions of affiliation and social imitation, where images dominate to convince viewers, even before a word is spoken, that they can and should achieve the modifications seen in pre-and-post op photos. And because medical providers favour nudging in health contexts, the use of influencer markets and ads in the form of nudging bots to direct Internet traffic their way is generally not considered problematic. In fact, getting online first, though couched as fighting misinformation, is basic to savvy business marketing. And even content deemed “educational” is problematic in targeting individuals online. Health messages can be deployed by self-interested profit-driven medicine through automated accounts and followers as part of undisclosed bot advertising, which, according to a 2019 study, has come to represent a “black market of engagement [that] implies the drive of fake followers, likes and comments to accomplish a particular purpose - namely popularity, the spread of political ideas, demonstration of influence, etc.”

Moreover, curated bots are sophisticated enough to ask questions. Posing questions is actually a form of nudge, and the detrimental potential of nudging bots is most evident when it comes to binding. Health bots are designed to identify symptoms and suggest solutions. Significantly, the evidence linking the suggestion to bind in response to distress is a trans phenomenon that originated online rather than from clinics. As a necessary psychological precursor to surgery, coping mechanisms such as binding can readily be echoed or amplified by bot activity. On the whole, binders seem designed to fail, leading eventually to the pursuit of seeking a surgical remedy. And in this way, a seemingly harmless health nudge in the form of a bot leads eventually to big-ticket surgical interventions.

Distress Can Turn into Dissociation

Automated health bots can thus infiltrate insular millennial and gen Z self-help enclaves as an unsuspected influence operation opening up seats on the trans-train. In the before- and just- after-the-trans honeymoon ecology on Tumblr, debating what it means to be trans is an engine of distress; it’s a claim of pathology. Becoming entrenched in defending a chicken or egg position on either side requires tacit acquiescence to trans-ideology. While the suffering is real, health bots can echo the need for hormones and surgeries as necessary and the only way to gain relief. Because of this newest wagging of Pavlov’s dog, resolution is claimed primarily through medicalisation. Social media makes possible massive affirming — and amplification — of bodily hatred. Because humans are wired for social cohesion, emotions in themselves are transferable; sure enough, there’s a well-documented connection between emotions and physical well-being. Peer comparison, feedback loops, and the need to fit in all favour mutual questioning of identity, intensification of distress, and a push for trans-medicine.

The rush for trans-medicine takes advantage of well-known effects of group cohesion and fandom. Justified by the presumed need for privacy and safety, social media such as Tumblr block anyone raising concerns. In praise of this approach, what they elsewhere call “trans technology,” researchers Oliver L. Haimson, et. al., explain “Tumblr supported trans experiences by enabling users to change over time within a network of similar others, separate from their network of existing connections, and to embody (in a digital space) identities that would eventually become material.” A secret cohort group is thus fostered within self-help groups on social media. Anything from garden variety gender nonconformity to the creative can be re-construed as trans.

Privacy and safety in this context serve a creepy form of inward-facing insulation from any and all reasoned critique. Entry to the in-group means accepting an affirm-only ground rule in the same way anorexics congregate on Tumblr to corroborate they are legit dieters. Helena, who became trans-identified for a time, observes: “Tumblr is designed in a way that fundamentally enables extreme groupthink, manipulation of information, destructive interactions, and distorted ways of thinking.” Like concert screamers, the participants fiercely guard their shared fandom, showing off their scars and “insisting that it’s worth the pain, that they’ll love how they look and they won’t regret it." The need to defend any critique of trans, as Eliza Mondegreen has reported after analysing online forum discussions, means any questioning of the results not living up to expectations will be concluded with the adage “I must have internalised transphobia." Flagging for the destruction of actual physical body parts surely qualifies in any but the most depersonalised gender fan as internalising self hatred.

Based as it is in the new anthropology of human identity, social media confirms the possibility that one is born wrong. A self-diagnosis of dysphoria ratified first on social media and later in clinical settings, guarantees access to trans-medicine. The problem with this lack of self regard and later dearth of safeguarding is seen in the results. Instead of providing ways to recover self-acceptance, a diagnosis of dysphoria leads to dissociation and self- harm according to Amy Sousa, MA in depth psychology. Sousa suggests the diagnosis perpetuates a false mind/ body split, hence reinforcing dissociation from the body. Rather than suggesting ways to explore underlying causes of dysphoria, social media chatbots act to amplify distress.

No More Holiday for Long-Term Damages

At long last, the end of Trans Inc. is in sight along with its influencer surgeons and clinic promoters on social media. Worldwide, trans-medicine is facing legal limits as Sweden, Finland, and the UK all restrict or entirely curtail trans-medicine. And generally, the trans push on social media is well known: “There is evidence that vulnerable young people are being actively recruited and coached on such sites [as Tumblr] to believe that they are trans. Social contagion is almost certainly playing a role as well. Social media presents a flattened, mirrored world where intensely experienced distress is documented and, like a curtain dramatically flung wide, apparently alleviated. Yet, the ephemeral nature of the results as well as the role of an online gender matrix that can traffic young people toward the trans mill is now evidentiary material.

The recognition of hidden persuaders operating within the context of social media marketing to build a patient base for trans medicine is thus now the major subtext of a recent legal case. Medical professionals at the Nebraska Medical Center and Nebraska Medicine are currently being charged with negligence and malpractice for failing “’to meet the standard of care by recommending and/or performing irreversible transgender procedures when {trans-identifying patient} Luka may have been swept up in a social contagion and/or unduly influenced by social media.’ Luka Hein, who was then 16, explains, ‘I was going through the darkest and most chaotic time in my life, and instead of being given the help I needed, these doctors affirmed that chaos into reality...I was talked into medical intervention that I could not fully understand the long-term impacts and consequences.’" Understanding the powerful role of trans-influencer markets on social media is a game changer.

Every human being is impressionable to social pressures. It needs to be said that anyone can be nudged to seek the bot-amplified “options” timed into our social media feed to meet a perceived need. Those experiencing distress are, of course, more vulnerable to promises of euphoric relief; it is the resurfacing of distress in combination with delayed harms that is at last subject to legal scrutiny.

Legally, the free pass trans-medicine has enjoyed is expiring as the statute of limitation for making a claim is extended in some states, allowing patients to sue. Recent headlines reveal looming liability is pausing Missouri trans-medicine. Following new legislation, patients who previously only had two years to file lawsuits will now have 15 years. Citing the newly expanded timeline for filing, both Washington University in St. Louis and the University of Missouri Health are cancelling prescriptions for puberty blockers and hormones. That longer filing time brings into view the many health risks due to trans-medicine.

While Canadians may face more legal hurdles than in the plaintiff-friendly US courts, the UK has already witnessed intense litigation aimed at affirm-only doctors and clinics. Hospital administrators and surgeons no doubt realise they’ve opened themselves up to liability because non-FDA approved hormones and trans surgeries are deemed experimental thus unsafe.

Social media has also shaped the mentality of the public. Acquiescing to the demands of bot-hacked echo chambers on social media has been detrimental, but it has largely played out at a stealth level. Medical providers will now hesitate to pay for bots to drive traffic their way. After all, the social media pipelines can fast track profit only so far before the long-ignored consequences of trans-medicine, and its bots, no longer remain hidden.


Dr. Faith Kuzma is a retired Assistant Professor of English. Kuzma has written for Salvo, The Canadian Patriot, Psych Reg, and Mercator Net and elsewhere. Find her @faithkuz


*Note: Subcultures thrived on Tumblr. Up until it banned adult content in 2018, Tumblr provided unrestricted posts from content creators who originated influencer communities within the LGBTQ + subculture. Their inclusion of partially nude photos within an educational and medical context was interpreted by Tumblr’s newly-instituted 2018 algorithm as inappropriate. The ensuing complaints (and departures) over porn bots still flourishing even as censor bots flagged LGBTQ + photos helped reveal the black market of bot engagement. Since the backlash, the site promised its machine-learning algorithm would continue to function as it had before the new constraints.

Likewise, dysphoria as a diagnosis and affirmation only as an approach are both increasingly questioned by therapists.

End Notes:

"Lupron manufacturer AbbVie made $726 million on the drug alone in 2018. AbbVie has joined other major pharmaceutical companies in lobbying to keep drug prices high while virtue signalling about diversity and inclusion.”

602 views0 comments

Recent Posts

See All


bottom of page