RSS

Understanding Gender Dysphoria – Part 5

Bert and Faye had been married some 30 years when they came to my office for a consultation. Each of their three children (2 biological and one adopted) had been out of the house now for a couple of years, two were married, and one was now expecting their first grandchild. The reason they came for a consultation was Bert’s relatively recent (within the past 3 years) revelation to Faye that he was a woman. This was really difficult for Faye to process. She would look at me and say, “Does this make any sense to you at all?” In a private meeting, Bert shared with me that he had known about his gender dysphoria for many years before he disclosed to Faye, but he had not known what it was before then. He thought he was losing his mind. He did not have a name for what he experienced, and that lack of understanding only intensified his confusion and distress. He has begun cross-dressing intermittently by wearing female undergarments. He is interested in presenting as female but he and Faye agree that doing so locally would not be advisable. He has considered doing so on business trips, which he takes about every 3-4 weeks to larger cities around the country. He believes that this level of cross-gender identification will likely help him manage his dysphoria by helping him express who he experiences himself to be.

Gender Dysphoria coverAs the story of Bert and Faye exemplifies, the challenges in adult experiences of gender dysphoria are numerous and complex. The last post in our series addressed gender dysphoria in childhood and adolescence, including some of the controversies surrounding prevention and intervention. In this post we reflect on what happens in cases in which gender dysphoria does not resolve–in cases in which the child or adolescent is now an adult who reports an ongoing incongruence between their biological sex and their gender identity. What happens to this person? How does the story end?

In researching answers to these questions, I was surprised to learn that in many cases (an estimated 50% of cases), we actually do not know the answers to these questions. In other words, many people have unresolved outcomes in which we just do not know what happens to a person (again, as many as half of all cases).

Of cases that are tracked and where we do know what happens, it is typically understood that there are three pathways. The first path is to attempt to live one’s gender role and identity in keeping with one’s biological sex. The person may feel gender dysphoric, but they live as their birth sex and corresponding gender identity/role and adopt a lifestyle that reflects that. In the case of Bert and Faye, Bert shared that he would have liked to have experienced some kind of resolution like this, especially if it meant he and Faye could stay married and avoid predictable social stigma in their rather small and conservative hometown. Faye definitely wanted this resolution.

The second path is to engage in cross-gender behavior intermittently. Bert did try this for several years. For a biological male, this might mean growing his hair out longer, wearing make-up occasionally, and cross-dressing either on the weekends or wearing female undergarments during the day to manage the dysphoria. Think of this as a continuum. The extent of cross-dressing behavior varies considerably and typically reflects the degree of dysphoria and how successfully such cross-dressing behaviors reduces or makes the dysphoria more manageable.

The third path is to adopt a cross-gender role and identity. This may or may not involve hormonal treatment and sex reassignment surgery. Many people do not pursue these steps for a variety of reasons. In any case, the last path is reflected in those who cross-gender identify (or adopt the gender identity and role of the opposite sex). Throughout this whole process and again with the discussion of hormonal therapy and/or surgery, most mental health professionals reference the widely-recognized Standards of Care of the World Professional Association for Transgender Health (WPATH; formerly referred to in the literature as the Harry Benjamin International Gender Dysphoria Standards of Care).

If you are interested in this topic, you might be interested in the previous posts in this series. Also, there is so much more to say about these potential pathways and research on outcomes. Learn more by reading, Understanding Gender Dysphoria, forthcoming from InterVarsity Press Academic. The publisher recently released an excerpt if you would like to check it out here.

 
1 Comment

Posted by on May 4, 2015 in Uncategorized

 

Understanding Gender Dysphoria – Part 4

Gender Dysphoria cover“What can we do?” asked the mother of a 7-year-old boy. She looked up and caught my eye. “What should we do… just last week a woman at the park said something. I couldn’t believe she had the nerve, but she did. I’m worried about him; I’m afraid that kids at school might do worse. There have been a few things said, at least he has hinted at a couple of things. But that could get worse. How they might tease him… I don’t know…” The mother went on to describe her son’s effeminate behavior and mannerisms, as well as how his voice inflection seemed more like that of a girls. She spoke of his tendency to pretend he had long hair and declare, “Mom, I have long hair like you have long hair!” She shared that just this past weekend, he grabbed a towel and put it around his waist and said, “Look, Mom, I’m wearing a dress just like you!” And he would often put on her heeled shoes and walk around in them.

This is obviously a challenging situation for parents, who are often unsure how best to respond to their child. Parents often wonder if this is a phase their child is going through. They may wonder if their child is going to be gay. Most do not know what gender incongruence or gender dysphoria is, so that is often not even on their radar.

Discussions about prevention and/or intervention can be remarkably complicated. Not only are the parents and the child obvious stakeholders, but there are entire emerging communities that have a stake in what happens next. Before we discuss four general approaches that have been in the literature, it is important to know that most cases of Gender Dysphoria (in which the diagnosis applies) actually resolve before a child reaches late adolescence or adulthood. Researchers sometimes refer to “desisters” and “persisters.” A desister is someone for whom the gender dysphoria resolves by late adolescence or adulthood, whereas a persister refers to someone who continues to experience gender dysphoria into later adolescence and adulthood. I discussed developmental trajectories among gender dysphoric children in a previous post, and that might be helpful to review.

So the question of whether and how to intervene is often held up to scrutiny in light of what appears to be a natural resolution of Gender Dysphoria among desisters. But we do not know enough today about how to distinguish children whose gender dysphoria desists from those whose gender dysphoria persists. You can begin to appreciate how not knowing makes every other decision that much more difficult.

There are four basic approaches under consideration:

Decrease cross-gender identification;

Watchful waiting;

Facilitate cross-gender identity in anticipation of an adult identification; and

Delay puberty until a child can decide about gender identity in later adolescence.

Proponents who discuss the first option generally argue that they are facilitating a resolution that is likely to occur anyway. They tend to emphasize the concern that a child will face a difficult social atmosphere in which peer group disapproval takes its toll. One proponent of this model has written about a protocol to facilitate the resolution of Gender Dysphoria among biological males. It includes interventions such as fostering/facilitating (1) positive relationship with the child’s father or male caregiver or role model; (2) positive relationships with the child’s male peers; (3) gender-typical habits/skills; and (4) male peer group interactions. Interventions are really with the parents who then foster/facilitate these interests with the child.

There was an interesting National Public Radio report a few years ago on whether and how to intervene with gender dysphoric children. The NPR report cited The Portman Clinic’s treatment of 124 children since 1989 using a comparable approach, and it was reported that 80% of the children chose later as adults to maintain a gender identity consistent with their birth sex.

Those who are critical of this kind of intervention express concern about the prevention of gender variant expressions and/or homosexuality (as most desisters do later identify as gay, lesbian, or bisexual), and some wonder whether those who live consistent with their birth sex are natural desisters whose gender dysphoria would have resolved anyway.

Those who argue for watchful waiting anticipate that as a child’s gender identify unfolds, it will be clear whether the child will desist or persist, and that what occurs naturally, if you will, is likely to be the preferred outcome in these that any other resolution will likely go against the grain of what is unfolding. Cross-gender interests are permitted here, and the parents try to be as neutral as possible in response to the child’s expressed interests. In addition to providing a neutral environment with respect to cross-gender behavior and identity, watchful waiting as an approach emphasizes helping the family attend to their anxiety about the outcome and to facilitate a positive view of self for the child.

Concerns here tend to be around the practical issues involved in being truly neutral about gender identity. Also, there is a philosophical concern about whether what is being referred to as a natural unfolding is the best or most reliable guide to gender identity resolutions.

The third approaches supports and facilitates exploration and adoption of the preferred gender identity. I am distinguishing it from a fourth option in which puberty is actually delayed to provide more time for an older child to enter into adolescence and make decisions closer to age 15 or 16 about gender identity. In other words, parents may elect to facilitate cross-gender identification (rather than be neutral) (option three) but may not wish to delay puberty through the administration of hormone blockers (option four).

If we return to the NPR report we see research cited in support of puberty suppression as well. Researchers in the Netherlands have  been following children who underwent hormone-blocking treatment, and in their report on 100 patients, all had made the decision as adults to live as their preferred gender identity (rather than their birth sex). Criticisms of this approach range from the effects on bone-mass development to brain development to questions as to whether co-occurring mental health issues are resolved. Sterility is also a concern. Proponents of puberty suppression say that each of these concerns must also be weighed against risks associated with delaying intervention.

Of course, there are additional criticisms and concerns with each of these four options as well. I just wanted to map out the different paths that are under consideration. Many factors go into making a decision as a parent, and no one decision may be the best decision for every child or family. Decisions should be made in the context of a good assessment, accurate diagnosis, and with an experienced team.

Once a child enters later adolescence or adulthood, we are having a different discussion about ways to manage gender dysphoria. I will either do another post on that or encourage the interested reader to see that part of the forthcoming book, Understanding Gender Dysphoria.

___

Note: This blog post is Part 4 of a series. If you found this interesting, you may want to read Part 1, Part 2, and Part 3.  Also of interest may be a recent talk I gave at Calvin College titled Understanding Gender Dysphoria. The book I mentioned can be pre-ordered through IVP or Amazon.

 
Leave a comment

Posted by on April 3, 2015 in Gender Identity, Transgender

 

Tags: , ,

Understanding Gender Dysphoria – Part 3

Gender Dysphoria cover“I don’t think you chose to experience gender dysphoria,” I offered slowly, looking at Jeremy who had been looking away ever since he explained how long he had felt different from other boys he knew. He hadn’t held eye contact once since he began talking about the time his mother caught him dressing in his sister’s clothing one day after school. He wouldn’t look at me when he shared how his father confronted him that same night when he came home from work. After I spoke, he turned toward me to catch my eye, as if he wanted to confirm I wasn’t just saying this to make him feel better. You see, he had been told by Christian leaders just the opposite—that he had indeed chosen to feel like a girl; that his experience of gender dysphoria was an act of willful disobedience to be confronted by his parents if they hoped to help him, if they hoped to save him.

It is a remarkable claim to declare that an adolescent is choosing gender dysphoria to make life difficult for his parents or to essentially thumb his nose at God as Creator and at his own body as a part of the creation.

In this blog post I want to introduce the topic of etiology or causation. The question is: What causes someone to experience gender dysphoria? Recall that gender dysphoria refers to the incongruence between one’s biological/birth sex and one’s psychological and emotional experience of gender identity. One possible benefit to discussing causation is to improve the exchanges between Christian leaders and someone like Jeremy.

Let me first acknowledge limitations to research in this area. These limitations should help us take a posture of humility toward the topic of gender dysphoria, toward what we know and what we do not know.

When we discuss who is transgender, we quickly realize that while this is an umbrella term, there is not consensus as to who is transgender. Put differently, there is great heterogeneity among these different phenomena. A range of people  may identify as transgender. In a chapter he wrote on the topic, Richard Carroll recognizes “transsexuals, transvestites, she-males, queers, third sex, two-spirit, drag queens, drag kings, and cross-dressers.” Not all of these folks will experience gender dysphoria, and many would not feel comfortable including everyone else under the umbrella of “transgender.”

How this is related to research on causation? The heterogeneity represented under the transgender umbrella makes it difficult to conduct research on causation. We have to begin by identifying the key variables and then finding ways to operationalize and measure those variables. If we are trying to explain cross-dressing behavior, for example, we have to acknowledge that not everyone who cross-dresses experiences gender dysphoria. Not everyone who identifies as transgender either cross dresses or experiences gender dysphoria.

Most of the research on causation is limited to transsexuals. In some ways this can be helpful, as most transsexual persons presumably experience sufficient gender dysphoria such that they form a cross-gender identity and may pursue hormonal treatment and/or sex reassignment surgery. However, the experience of diagnosable gender dysphoria is rather rare, and finding a sufficient number of transsexual persons for research purposes can be problematic. Most of these studies are conducted with small samples, which is just one of many potential limitations to research in this area.

In any case, the most popular theory of causation today is called the brain-sex theory. The brain-sex theory holds that transsexuality is essentially biological in origin. It might be thought of as (in the words of Milton Diamond) an “intersex condition of the brain.” The theory is based on the understanding that sex differentiation of the genitalia and sex differentiation of the brain occurs at different stages of fetal development. The idea is that perhaps in rare instances the genitals develop in one direction while the brain develops in the other direction.

In support of this theory, the most widely-cited studies have been on neuroanatomical structures of the brain. Proponents believe that differences in size and volume of cells in specific regions of the brain suggest a biological basis for etiology. Other studies in support of the brain-sex theory have been conducted as well, and I discuss these in greater detail in the book that will be out in June.

There are other theories of causation that do not receive as much attention. They tend to be multifactorial models with more consideration given to psychosocial factors. Proponents of these models suggest there are–in addition to prenatal/biological considerations–differences in areas such as temperament, level of anxiety, sensory reactivity, same-gender parental identification and modeling, and early childhood trauma that may also be part of the picture.

I also want to acknowledge that research is not conducted in a vacuum. It is conducted in a sociocultural context. Today that context is one in which identity has emerged as particularly salient. It has figured prominently in what Cressida Heyes refers to as the “gay liberation movement,” which focused historically on equality for gay and lesbian persons: “Visible early lesbian and gay activists emphasized the immutable and essential natures of their sexual identities. For some, they were a distinctively different natural kind of person, with the same rights as heterosexuals (another natural kind) to find fulfillment in marriage, property ownership, and so on.” This kind of focus on identity can also be part of the motivation to conduct research with a focus on biological bases for gender dysphoria. That is, there would then be a more identity-focused discussion of transgender kinds of persons that can be distinguished from cisgender kinds of persons. My sense is that in the minds of many proponents of transgender interests, research on biology lends itself to the kind of argument in favor of an “essential nature” related to gender identity.

I think the most accurate answer to the question of causation is this: We don’t know what causes gender dysphoria. While the research in this area has been going on for many years now, there just is not that much data to point to for a final word on causation.

When I think of Jeremy, the person I was talking to who had been told by Christian leaders that he chose his experience of gender incongruence, I have to urge those who minister to people like him to resist the pressure to have the answer at that moment. It is okay to not know what causes a person’s experience of gender dysphoria. I say this to people all the time. I have found it much more helpful to take a posture of humility about causation and to focus on care. To do this, you could always ask the person, What would it mean for you to know what caused your experiences of gender dysphoria? This question may open up a more helpful discussion of meaning and purpose that may guide efforts to provide support as the person navigates questions of gender identity.

___

Note: This blog post is Part 3 of a series. If you found this interesting, you may want to read Part 1 and Part 2. Also of interest may be a recent talk I gave at Calvin College titled Understanding Gender Dysphoria. The book I mentioned can be pre-ordered through IVP or Amazon.

 
Leave a comment

Posted by on March 13, 2015 in Gender Identity, Transgender

 

Tags: ,

The Calvin College Talk on Gender Dysphoria

The AV staff at Calvin College have been working on a better quality video of the talk I gave titled Understanding Gender Dysphoria: Navigating Transgender Issues in a Changing Culture. Here is the video. It is about an hour with some Q&A from the audience:

Several transgender and gender variant people and families who have loved ones who are under the transgender umbrella have reached out to me following the talk. They are hungry for resources and for a way forward.  If I were to summarize the themes from those exchanges so far (and some are ongoing), I would say they are centered on (1) self understanding (How do I understand what I am going through?), (2) the faith community (How do I have more constructive discussions with pastors and others in my church?), and (3) How do I improve existing relationships with loved ones? In some ways these are similar to what we reported in our research with male-to-female transgender Christians a few years ago. I think these themes also line up with what I have seen in counseling individuals, couples, and families over the years.

These are important, significant discussions for every individual and family that is navigating this terrain. So many feel alone and unsure how to even begin a conversation. The section from the presentation on different “lenses” through which different stakeholders “see” the issues and people seemed especially promising to them. There is certainly much more that can be done to be a resource for responsible care in these three areas, and I hope that ongoing discussions and future discussions will be a part of seeing that come about.

 

 

 

 
Leave a comment

Posted by on February 11, 2015 in Gender Identity, Transgender

 

Tags: , ,

Understanding Gender Dysphoria – Pt 2

tg laverne coxCalvin College has hosted a Sexuality Series for several years now, and just this past week I had the opportunity to participate in the series and to speak on the topic of our series: Gender Dysphoria. If you would like to watch that talk, you can see it here. It will provide you with a sense for where the series is headed.

In the past several years our culture has changed dramatically in terms of popular cultural and professional acceptance of transgender persons. In the popular culture, we see this in the recent Time magazine cover and popularity of shows that have transgender characters. Our culture has in many 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 reflect the cultural sea change that would soon follow.

In the professional literature, the Diagnostic and Statistical Manual of Mental Disorders-fifth edition (DSM-5) reflected a shift away from Gender Identity Disorder toward the use of the phrase Gender Dysphoria 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.

In my forthcoming book, Understanding Gender Dysphoria, I define numerous key terms. Let me cover three here:

Gender dysphoria: The experience distress associated with the incongruence wherein one’s psychological and emotional gender identity does not match one’s biological sex.

Transgender: An umbrella term for the many ways in which people might experience and/or present, express (or live out) their gender identities differently from people whose sense of gender identity is congruent with their biological sex.

Transsexual: A person who believes he or she was born in the “wrong” body (of the other sex) and wishes to transition (or has transitioned) through hormonal treatment and sex reassignment surgery.

There are expressions of what we often refer to as gender variance that would not necessarily report gender dysphoria. For example, most people who have an intersex condition (e.g., congenital adrenal hyperplasia), do not report gender dysphoria. They may have a higher incidence rate than those who do not have an intersex condition, but gender dysphoria is not a given for someone with an intersex condition. Nor would it be common for a person performing drag. That person may not even think of him or herself as transgender, and many in the transgender community would not think the transgender umbrella covers most drag kings and queens.

So it’s complicated. This is an area that requires time and patience to unpack and truly understand—and even then, we do so with humility given how much we do not know at this time. But Christians are going to need to spend some time on this topic–to spend time in careful reflection as we think about the best way to engage the broader culture while simultaneously considering how to come alongside people within our own Christian communities who are navigating this terrain.

MTF articleAs I bring this post to a close, I want to point out that there has been one study published of male-to-female transgender Christians. My research team conducted this study a couple of years ago. It was a study that addressed gender identity and religious identity in terms of personal faith, God, and the local church. Perhaps surprisingly, some transgender Christians shared that their gender dysphoria led to a strengthening of their personal faith; others reported a past struggle with their faith, and still others left the organized religion with which they grew up. For some, the challenges they faced brought them closer to God, but others reported a strained relationship with God because of their gender dysphoria. What was particularly common were past conflict with the local church community or the persons and leaders who represent these organizations. I’m sure I’ll come back to this study in a future post, but needless to say, it provides an interesting perspective on the topic.

Most people approach this topic with one question in mind: What are you for (and what are you against) in terms of resolution? I have not found this question to be exceedingly helpful over the years I’ve worked with gender dysphoric persons. As I’ve mentioned previously, it is unclear to me at this time that there is any one outcome that is ultimately satisfying to everyone who has a stake in these discussions. It is such a rare condition that we little good research from which to draw strong conclusions, and I have known people who felt gender dysphoria so strongly that they felt that nothing less than their sanity and their life was at stake. They desperately sought a resolution to a dysphoria that caused them significant distress and impairment. This is not an argument that they then should pursue the most invasive procedures, but I can understand and empathize with that decision, as painful as it often is. Rather than reject the person facing such conflicts, the Christian community would do well to recognize the conflict and try to work with the person to find a path. There is an opportunity here to learn much more than we know at present, and we would do well to enter into the discussion with patience and humility, as we balance multiple perspectives on how best to resolve what people often report to be an impossible situation.

 

Tags: , , ,

Understanding Gender Dysphoria – Pt 1

A male-to-female transsexual Christian, who I will refer to as Sara, opened an exchange with me with a reflection on her decision to pursue hormonal treatment and sex reassignment surgery: “I may have sinned in the decisions I made; I’m honestly not sure that I did the right thing. At the time, I felt excruciating distress. I thought I would take my life. I can’t imagine going back. What would have me do?”

That is a pretty disarming exchange. This is not someone who has made a commitment to a worldview and philosophy bent on deconstructing meaningful categories of sex and gender. If you had come to argue with Sara about a sexual ethic, you would not have found an opponent. She might have agreed with you, in fact. How does a person like Sarah maintain a posture of repentance and a soft heart toward God in light of the impossible decisions she faced? Is there a Christian community that is willing to stand next to her in these impossible circumstances?

As a psychological condition, Gender Dysphoria is such a rare condition that we little good research from which to draw strong conclusions. I have known people like Sara who experienced gender incongruence and a rise in the associated distress so strongly that they felt that nothing less than their sanity and their life was at stake. They desperately sought a resolution. This is not an argument that they then should pursue the most invasive procedures or cross-gender identification, but I also acknowledge that I understand and empathize with that decision, as painful as it often is.

Gender Dysphoria coverI am going to start a series titled Understanding Gender Dysphoria in anticipation of a forthcoming book that is scheduled to be published by InterVarsity Press Academic in July of 2015. It is titled Understanding Gender Dysphoria: Navigating Transgender Issues in a Changing Culture. In it I define key terms and explore the experiences of those who are accurately diagnosed with Gender Dysphoria and discuss some of the controversies in prevention and resolution of gender identity conflicts, as well as offer an integrated framework for how Christians might respond.

Here is the description from IVP Academic:

Few topics are more contested today than gender identity. In the fog of the culture war, complex issues like gender dysphoria are reduced to slogans and sound bites. And while the war rages over language, institutions and political allegiances, transgender individuals are the ones who end up being the casualties.

Mark Yarhouse…challenges the church to rise above the political hostilities and listen to people’s stories. In Understanding Gender Dysphoria, Yarhouse offers a Christian perspective on transgender issues that eschews simplistic answers and appreciates the psychological and theological complexity. The result is a book that engages the latest research while remaining pastorally sensitive to the experiences of each person.

In the midst of a tense political climate, Yarhouse calls Christians to come alongside those on the margins and stand with them as they resolve their questions and concerns about gender identity. Understanding Gender Dysphoria is the book we need to navigate these stormy cultural waters.

This is a difficult topic for many people. Evangelical Christians, in particular, are not adequately prepared to meaningfully engage the topic of Gender Dysphoria today. What interests me most is the opportunity to help individual Christians (pastors, parents, friends) and the church position themselves to help those who are navigating the difficult terrain of gender identity concerns and engage the topic in a more constructive manner.

If the topic interests you, the book can be pre-ordered through IVP or Amazon. In the meantime, join me in a discussion of Gender Dysphoria over the next several months. Also, if you are in the Grand Rapids, MI, area, join me at Calvin College on February 5th as I’ll be speaking on Gender Dysphoria for their Sexuality Series.

 
1 Comment

Posted by on January 14, 2015 in Gender Identity, Transgender

 

Entering 2015

As many of you know by now, I am not particularly good at blogging. Everyone has already posted their top posts from 2014, and I am just now getting around to looking at the stats. For those who are interested in that sort of thing, it looks like the top post was this most recent one, On the Expectation of Change.This was the post suggesting we show more caution in how we interpret findings from the study I was co-author of on people attempting to change sexual orientation through involvement in Christian ministries. The main point was about how those findings might inform ministry and the expectation of change among Christians.

The other popular posts are actually older posts that have staying power (this is what wordpress tells you to give you some encouragement). These include a couple of posts on Value Conflicts in Counseling and the five-part series on Mixed Orientation Marriages.The former dealt with several legal cases in which graduate students refused to work with gay clients on goals that went against their religious beliefs and values and cited sincerely held religious beliefs as their rationale. The latter is a popular series on several studies we have conducted on people in mixed orientation marriages, which are marriages in which one person is a sexual minority (attracted to the same sex independent of behavior or identity label) while the other spouse is heterosexual.

Also popular is a seven-part series on the Psychology of Judgmentalism and a more recent post On Telling People How to Navigate Sexual Identity. The Psychology of Judementalism series was based on a book and opening reflections I was doing in a course on Ethics. The other post had to do with various resolutions people consider when they experience a conflict between their religious identity and sexual identity.

In any case, those are a few highlights if you are new to the blog. As we enter 2015 I anticipate new posts on a range of topics, including gender dysphoria, as I have a book that is due out in June/July of this year. I’ll blog a little more on that as we get closer to the publication date.

 
Leave a comment

Posted by on January 5, 2015 in Uncategorized

 
 
Follow

Get every new post delivered to your Inbox.

Join 100 other followers