Understanding Gender Dysphoria

  Understanding

  Gender

  Dysphoria

  Navigating Transgender Issues in a Changing Culture

  Mark A. Yarhouse

  www.IVPress.com/academic

  To the church, the Body of Christ:

  For wisdom in walking with those who are navigating gender identity

  concerns and questions of faith. That we may all experience

  the love of the Father, the peace of Christ and

  the presence of the Holy Spirit.

  Contents

  Introduction

  1 Gender Identity, Gender Dysphoria and Appreciating Complexity

  2 A Christian Perspective on Gender Dysphoria

  3 What Causes Gender Dysphoria?

  4 Phenomenology and Prevalence

  5 Prevention and Treatment of Gender Dysphoria

  6 Toward a Christian Response: At the Level of the Individual

  7 Toward a Christian Response: At the Level of the Institution

  Notes

  Index

  CAPS

  Praise for Understanding Gender Dysphoria

  About the Author

  More Titles from InterVarsity Press

  Introduction

  Most of my professional work has been in the area of sexual identity or the act of labeling oneself based on one’s sexual attractions. In that area of scholarship, I try to be clear about what we know and do not know about sexual identity, while identifying ways in which current research can inform our understanding of how Christians in particular navigate sexual identity questions in their own lives.

  Several years ago I was talking with a colleague who was aware of the intense level of scrutiny I receive for my work, often receiving criticism from people or organizations on both sides of the broader culture wars. I was providing a consultation for a family whose daughter was gender dysphoric. He said, “That’s a good idea; maybe move into a less controversial area of work.” He was serious! It was one of those funny moments because I realized he did not know how controversial the issues are surrounding gender dysphoria and transgenderism.

  That has been confirmed for me as I have conducted research for this book: no one is satisfied with anyone else’s perspective on the topic of gender identity. There are considerable professional and popular divisions that have made it a virtual minefield for any author who wants to step foot on this terrain.

  So I want to tread cautiously.

  At the same time, I have spent years now meeting with children, adolescents and adults who have been navigating gender identity concerns, and I have had the opportunity to publish one of the first studies of its kind on a sample of Christians who are transgender. With the revelation of popular figures identifying as trans (e.g., Cher’s child who is a biological female and named Chastity Bono at birth and now identifies as male, Chaz Bono) and legal challenges in Christian institutions for transgender students, faculty and staff, this topic is clearly moving toward greater cultural salience.

  The fact is that there is a need for a resource that is written from a Christian perspective and is also informed by the best research we have to date, as well as seasoned with compassion for the person who is navigating gender dysphoria. I thought it would be worth trying to put together that kind of resource, and the reader will be left to decide whether I have succeeded, as the whole topic is difficult to fully understand let alone explain.

  One of the first times I moved from professional discussions about gender dysphoria to a more personal discussion was a few years ago. I had met an acquaintance who is a male-to-female transsexual person and a Christian and who lived not too far away. She accepted my invitation to join my family for dinner one day after church. I had not really thought much about it. My parents invited people over for dinner all the time when I was a kid growing up in Pennsylvania and Maryland. But my parents tended to invite missionaries who were home on furlough. This was going to be different, and I don’t know that I thought it all through. Then, as we spoke about finalizing the invitation, I realized she was bringing her wife. I hadn’t really asked much about relationships throughout our initial exchanges. As they shared with me, they were conservative Christians who had been married and raised a family together. They did not believe in divorce. At the same time, they looked like a lesbian couple. I was then beginning to appreciate how complicated this could get.

  This experience, together with other personal and professional experiences, led my research group to a series of trainings and consultations around gender dysphoria and eventually the decision to conduct the study of the experiences of transgender Christians. In the course of conducting that study, we asked several questions of participants to ensure that they were Christians—questions about what being a Christian meant to them and so on. When I presented the results at the Virginia Psychological Association, I found myself presenting the gospel as I read through the content analysis of how participants responded during that part of the interview. Participants referenced a personal relationship with Jesus, recognizing Jesus as their Savior, and so on. At a talk I gave recently on gender dysphoria, a person in the audience challenged the assumption that the people were really Christians: “But how do you know they were Christians?” he asked. “Wouldn’t they just be saying what they thought you wanted to hear, to be included in the study?” I suppose so. That is always a consideration when conducting research. People can misrepresent themselves. But if we took out of every textbook every study that relied on that kind of self-report, we would have pretty thin resources, at least from the behavioral and social sciences. Back to the presentation: The majority of participants denoted starting a personal relationship with Jesus through being saved by grace through faith, thus claiming a conversion experience that is consistent with truth claims that are central tenets of Christianity. It was rather remarkable, really, and it was humbling to me as a Christian and as a researcher.

  This book invites Christians to reflect on several issues related to these findings, a broader research literature I will attempt to explain, and other anecdotal accounts. I would like the reader to gain greater insight into the experiences of people who navigate gender dysphoria, recognizing that there is no one story that can capture the range of experiences that exists today. In the opening chapter, I introduce the reader to the language, categories and key terms associated with the topic. I also note that as we wade into this particular pool, we are going to quickly be in the deep end, as the topic is complex.

  The second chapter helps us think through a biblical perspective on gender dysphoria and transgender issues more broadly. I look at the biblical passages that are frequently cited in these discussions. It is here that I also introduce the reader to three different frameworks or lenses through which the topic can be seen: the integrity framework, the disability framework and the diversity framework. In addition, I introduce an integrated framework that draws on the best of each of the other frameworks.

  Chapter three looks at the debates about causation. There has been a recent attempt to offer a unifying theory of causation (i.e., the brain-sex theory) that captures our current interest in biological explanatory frameworks. Proponents of the brain-sex theory have been criticized by proponents of other theories, and vice versa. I essentially conclude that we would do well to humbly admit that we do not know at this time what causes gender variance or transgender experiences, including transsexuality, which has been the primary focus of research to date.

  Chapter four explains the phenomenology and prevalence of gender identity issues. I review the current Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnostic criteria for Gender Dysphoria. Although the diagnosis of Gender Dysphoria (previously Gender Identity Disorder) is rare, recent research suggests gender dysphoria may be experienced along a continuum and that the various expressions of gender variance that fall under the umbrella of transgender are more common.

  Chapter five considers issues related to prevention and treatment, particularly when gender dysphoria rises to the level of a diagnosable condition. There are a considerable number of debates here, particularly whether gender dysphoria resolves naturally, whether it can be prevented from continuing into adolescence or adulthood, and whether it should be prevented. There are fewer debates among mental health professionals about treatment options for adults, although there are several paths adults take when they are navigating gender dysphoria, such as resolving to live according to one’s birth sex, managing dysphoria or expressing one’s preferred gender identity intermittently, or full-time cross-sex typed identification.

  Chapter six brings all of what we have covered into a Christian response to gender dysphoria. The focus in this chapter is at the level of the individual, as I discuss how to respond at the level of the individual in clinical practice and ministry contexts.

  The last chapter looks at how the church positions itself in relation to the broader culture with respect to gender dysphoria and transgender issues. This is particularly complicated, as the topic of gender dysphoria is subsumed under the transgender umbrella that has been closely associated with the topic of homosexuality. The church has struggled in the twenty-first century with how to conceptualize some of these concerns, as well as how to be a unified witness in the area of sexual ethics. At the level of the institution, there is a question as to what it means to be missional as a church given the dramatic changes in our culture within the past several decades.

 
I would like to acknowledge the many reviewers who provided me with feedback on earlier versions of the manuscript. I sought out people I knew who were familiar with the topic of gender dysphoria either personally or professionally. The range of perspectives is noteworthy and included transgender, genderqueer, and transsexual persons, each of whom is a Christian, as well as gay and lesbian Christians, and scholars and pastors who are straight and have never experienced gender dysphoria to my knowledge. Specifically, I would like to mention Trista Carr, Stanton Jones, Judson Poling, Julie Rodgers, Melinda Selmys, Sandra Stewart, William Struthers, Caryn LeMur, Peter Ould and Amy Williams. The final version is not one any of the reviewers would necessarily endorse, and I take responsibility for it as they were generous with their time and their suggestions, many of which (but not all) were incorporated into the final manuscript.

  1

  Gender Identity, Gender Dysphoria and Appreciating Complexity

  Introduction

  On May 30, 1926, George Jorgensen Sr. and Florence Jorgensen welcomed their son, George William Jorgensen, into the world. Danish Americans who had married only four years earlier, they would christen George Jr. in the Danish Lutheran Church a few weeks later.1 George Jr. grew up in New York City and graduated from Christopher Columbus High School in the Bronx. He was considered rather slight and frail and interpersonally shy. George Jr. avoided rough-and-tumble play, sports and other stereotypically male interests. He would go on to study photography at Mohawk College in Utica, and did a brief stint in the military. He later received training at a medical and dental assistance school in Manhattan.

  Growing up in New York, George Jr. often felt that he had some kind of sexual and emotional disorder. In search of answers, he would investigate possible explanations by scouring books and articles at the New York Academy of Medicine library. His fear was he was homosexual; after all, he was sexually attracted to men. However, that did not appear to explain everything. George Jr. eventually experimented with the female hormone estradiol, and he learned during this time about a possible intervention taking place in Sweden that extended his experiments into a more meaningful and satisfying resolution. He went overseas and eventually found Dr. Christian Hamburger, an endocrinologist who was willing to provide him with hormonal replacement therapy. George Jr. would later have his testicles and penis removed; he also had vaginal plastic surgery. In 1952, George Jr. changed his name to Christine Jorgensen out of respect for Dr. Christian Hamburger.

  We are talking about the 1950s. This course of events would make headlines. Indeed, the New York Daily News banner headline read in all capital letters: “EX-GI BECOMES BLONDE BEAUTY: OPERATIONS TRANFORM BRONX YOUTH.” Although Christine was not the first person to undergo sex-reassignment surgery, she noted in her autobiography that she was the most well known at that time.

  Gender identity concerns were not that well understood in the 1950s. Frankly, they are not that well understood today. There are many questions left unanswered about what causes a person to have the psychological experience of being born in the wrong body.

  Controversies also exist in the area of treatment or care: How should parents respond when a child displays behaviors more characteristic of the opposite sex? Should cross-gender identification be redirected toward identification with one’s birth sex? Should cross-gender identification be encouraged for a child who is already gender dysphoric? Should puberty be delayed to provide time for that kind of decision making? Or what options exist for teens and adults? Should they be encouraged to enter into therapy to resolve the conflict through psychological intervention? Is cross-gender identification to be avoided, or should it be facilitated? When people have tried different interventions, what has been helpful? What are the reasons people pursue hormonal treatment and sex-reassignment surgery? How often are these procedures helpful to people? What are the long-term effects of these kinds of interventions?

  These are remarkable complicated questions that deserve our attention.

  We are no longer answering these questions in a cultural context of the 1950s. One difference we can all acknowledge is that our culture has shifted toward more supportive and varied sexual and gender identity labels and communities that are very accessible to people and their families. There have certainly been increased attempts to understand and respond to this often bewildering experience.

  The changing culture can be seen in both professional and popular treatment of the phenomenon. In the professional literature, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)2 reflected a shift away from Gender Identity Disorder toward the use of the phrase Gender Dysphoria3 to reduce stigma. Actually, several steps in the new nomenclature were intended to reduce stigma. The first is the shift from an emphasis on identity as the disorder to the emphasis on the dysphoria or distress associated with the gender incongruence for many people who report it. The other was the wording to allow for someone to no longer meet criteria following a transition.

  Our culture has in some ways moved past the afternoon television shows that capitalized on “shock and awe” in their presentations, where you might see producers orchestrate a dramatic confrontation between a male-to-female transgender person who once dated a woman and is now surprising her with her true sense of self. These colorful presentations in the media were once an expression of almost gawking at the phenomenon, but they did not represent the kind of cultural sea change that would soon follow.

  The shift in the popular media can also be seen in journalism. A few years ago Barbara Walters aired a special in which she interviewed a young biological male who was being raised as a girl.4 In discussing the decision of the parents to raise their son as a daughter, there was tremendous compassion generated around the challenges those parents and that family faced. In that same story, Walters interviewed an adolescent female who identified as male (or, more accurately, as a female-to-male transgender person). Walters interviewed his parents and they shared the challenges they faced, particularly for the mother in terms of wanting this to resolve in a way that would return her daughter to her. These are heartbreaking stories and challenging for every­one involved.

  In response to this increased coverage, I asked the questions above: When a child is gender dysphoric, how should parents respond? Should parents raise a gender dysphoric child in the identity of the child’s biological sex? Should they facilitate cross-gender identification? Or should they take a “wait and see” posture with the assumption that the right direction for that child is what will unfold?

  In addition to questions about gender dysphoric children, What are the obligations for employers who have transgender employees? How should bathrooms be designated? Should medical coverage extend to hormonal treatment and sex-reassignment surgery? What about room assignments at campgrounds and at colleges and universities? What about hiring policies at churches, faith-based ministries, and at Christian colleges and universities?

  As churches consider relating to a dramatically changing culture, what steps should be taken to reach unchurched persons who identify as transgender or who are part of the transgender community? Are there specific steps that could be considered to accommodate the experiences of gender dysphoric persons who visit churches?

  In all of these discussions it should be noted, too, that the transgender experience is not one experience; it is best understood as an umbrella term for the many ways in which people might experience their gender identities differently from people whose gender identity is congruent with their birth sex. The experiences vary considerably and are only matched by presentation and expression or the living out of one’s gender identity, which can range from pushing against gender norms (gender “bending”) to cross dressing for sexual arousal to show/performance/ entertainment (drag) to transsexuality.

  The transgender community, then, is broadly defined, and it has positioned itself alongside sexual minorities in the broader cultural discourse. Sexual minorities are people who experience their sexual identity in ways that are different than those in the majority (gay, lesbian, bisexual). When we speak of sexual minorities, then, we are typically referring to how people navigate sexual identity and convey their sexual preferences to themselves privately or to others publicly (e.g., frequently using the self-defining attribution “I am gay”).