NAE Webinar on Pastoral Care for LGBT+ Persons and Their Families

A short while ago the National Association of Evangelicals (NAE) asked me to record a webinar titled “Pastoral Care of LGBT+ Persons and Their Families.” That webinar is now available at their web site here for a modest fee. Here is the description:

While the national debate surrounding bathroom policies for transgender persons continues, evangelicals consider how to best engage the topic and more generally how to care for the LGBT persons and their families in their midst.

In this one-hour webinar, psychologist Mark Yarhouse, author of “Understanding Gender Dysphoria” and founder of the Institute for the Study of Sexual Identity at Regent University, shares tools for compassionate and biblically faithful ministry to LGBT persons and their families.

Gender Dysphoria

Here is a chapel address I gave at Covenant College on the topic if Gender Dysphoria. I am usually asked to speak on sexual and religious identity (the intersection of gay, lesbian, bisexual identity and Christian faith); or I am asked to speak on sexuality more broadly (how to be a good steward of one’s sexuality or sexual impulses). So this is different.

We discussed having the chapel on the topic of Gender Dysphoria, which in recent months I’ve been asked to speak on a lot. Christian audiences have been really interested in the topic, but they often have little experience with it apart from media and entertainment. In any case, I hadn’t given a chapel address on the topic, so I thought this could be helpful.

The feedback from students was encouraging. Several came up to me throughout the day, and I received a few emails from students who experience Gender Dysphoria. It is a topic that students are discussing on Christian college campuses, but they often have little opportunity to explore different approaches to it. I don’t know that a chapel address changes that dramatically, but it does provide a venue for awareness of the experience and further discussion.

On Care for Those on the Margins

marginalizedA question I’m asked from time to time is some variation on the following: “Given that this is such a relatively small population, why do we allocate so much time and attention to it?”

I’ve had this question around sexual identity concerns, where roughly 6-8% of the population has at one time experienced same-sex attraction and 2-3% report a homosexual orientation. The question comes up a little more often when discussing gender dysphoria, which is quite rare, or even transgender persons, which is a broader umbrella, but still a smaller percentage than what is represented by gay and lesbian persons.

I usually acknowledge that more people in a given setting are navigating other concerns. For example, at a Christian college, far more students will be finding ways to respond to depression or anxiety or pornography than same-sex sexuality or gender dysphoria.

But the question seems to come out of a place of either inexperience or privilege. It’s typically asked by people who have no known connection to the topic or to persons represented by the topic.

I’ve never been asked that question by a Christian parent whose daughter has just come out. I’ve not been asked the question by a gay student who doesn’t know how to talk about his same-sex sexuality with anyone at his Christian college. Or a wife whose husband has announced he is a woman trapped in the body of a man.

For my point of view, we have to look at two things (at least). One thing to consider is that debates about sexuality and gender are imbued with significance both in the church and the broader culture. They have been front-and-center in the cultural wars and there have been mistakes made by many people who represent a range of stakeholders. We can all do better.

We can also consider whether it is simply the hallmark of the Christian to care about those at the margins. By definition, those at the margins will be underrepresented and a smaller overall number. But how we respond to them, how we find ways to identify their concerns and respond in a Christ-like manner is the stuff of Christianity. Whether we talk about the stranger in a strange land or the lost coin or the lost sheep or the lost son, it is part of what makes Christians Christ-like. It is in our DNA.

If these concerns are not your concerns, I can appreciate where you might raise this question. But can I invite you to get to know people for whom this is their concern? Would you consider spending some time with these folks and see if other questions come to mind?

Perhaps rather than ask why we spend time on a topic that represents a relatively small percent of people, you may find yourself asking why we haven’t spent time on this in the past, and why, when we have spent time on it, our efforts have not been nearly as constructive as perhaps they could have been.

 

The Cultural Salience of Gender Dysphoria

thAs we come to the close of 2015, let me take a moment to reflect on what has been a rather remarkable year with respect to gender dyshporia. For about 16 years now, I have seen individuals, couples, and families where a person was navigating gender dysphoria. It is not my primary area of research and clinical practice; that would be sexual identity. Gender dysphoria is thought to be a rare phenomenon, but conservative estimates have frequently come from the number of people seeking out specialty clinics in Europe. More recent approaches have been through national studies and the inclusion of “transgender” as a category option. Neither of these is a particularly accurate measure of prevalence. “Transgender” is itself an umbrella term for any number of experiences of gender identity that do not match those that align with one’s biological or birth sex. Those who experience gender dysphoria would be a subset of people who identify as transgender.

Earlier this year I was asked by the editor of Christianity Today (CT) to write a featured article on gender dysphoria for their magazine. The editor had watched a talk I gave at Calvin College in February and was looking for an article that would help the CT readership come to a better understanding of the topic. I had also just completed a book that was scheduled for publication by InterVarsity Press Academic in June/July, so that timing was actually pretty good. I agreed to write the article.

The CT article on gender dysphoria was recently listed as one of the most-read CT articles of 2015. The article has not been without its critics, however. One theologian wrote a critical response to it in First Things. The editors allowed me to write a reply, which you can read here. (The most insightful review I’ve read is here.)

As I have been thinking through the nature of the critiques, one acquaintance approached me with a typology that he thought might be helpful. He said it was not original to him, but he was sharing that there may be different callings and audiences in the mix. He offered a taxonomy of purposes and corresponding audiences:

  1. to instruct morally and to strengthen ethical resolve;
  2. to instruct for the purposes of pastoral response and engagement;
  3. to engage pastorally with individuals, that person in need, and families who are affected;
  4. to respond to the gay/gender activists, sometimes within the liberal church, and often those outside the church.

The thought that was being shared is that perhaps my article and primary area of work has been in #2 and #3, whereas conservative Christians who have raised concerns have as their primary role #1 and/or #4.

Gender Dysphoria coverIt’s an interesting thought, and one I will leave to the reader to discern. Part of where I think Christians who have raised concerns and I are potentially speaking past one another is that I am focusing on gender dysphoria and the management of the distress experienced by the person navigating gender identity conflicts. Some of my critics are tackling the entire transgender umbrella with many or all of its presentations. We are at times simply not discussing the same thing.

In any case, I do provide clinical services in this area and continue to work closely with individuals, couples, and families navigating gender identity concerns. I typically recommend people go to more comprehensive clinics with larger, multidisciplinary teams, but in many cases people prefer to see a Christian, and so I am willing to meet with those individuals/families. So #3 is certainly a part of my professional work. Also, the CT article itself was geared toward helping Christians have a more compassionate response to a complex phenomenon, so in that sense #2 seems quite relevant.

About two years ago I thought that gender dysphoria would represent a wave that would crest on evangelical Christians and that the church was not prepared for it. This dawned on my through a series of talks to youth ministers who increasingly faced complex ministry challenges associated with gender identity questions. These encounters were why I approached IVP Academic about the book. However, it would have been difficult to predict just how culturally salient gender dyshporia and the transgender experience would become (with multiple reality TV shows, prominent award-recipients, and so on).

As we head into 2016 it will be interesting to track just how salient these topics will become, what they will symbolize in our culture, and how the Christian community will respond. There are no easy answers. What I recommend is a thoughtful, prayerful approach, one characterized by humility about what we know and do not know, and a response that embodies conviction, civility, and compassion in all our exchanges within the Body of Christ and beyond.

 

 

Minister to What Lies Beneath the Surface

Iceberg-1024x767Icebergs are formed from the ice that breaks off of a larger body of ice, typically a glacier. The analogy of the iceberg is a familiar one. The idea is that there is so much under the surface that goes unnoticed. Our focus tends to be on what we see, on what is above the surface. But what is above the surface doesn’t tell the whole story. What is particularly noteworthy is what lies beneath.

I recently used this analogy to talk with youth ministers about how Christians often respond to identity labels and gender atypical expression. Identity labels or sexual identity refers to terms like gay, lesbian, bisexual, bi-curious, queer, and so on. Gender atypical expression might be in hairstyle or clothing or mannerisms associated with the other gender.

Many people in ministry react to the label or expression rather than to what needs or questions may reside under the surface. What might those needs and questions be?

In a recent workshop with youth ministers, Julie Rodgers and I discussed what we see as the most frequently asked question teens wonder about. That question is: “Do you want me here?” There are many ways in which those in ministry and fellow youth may essentially answer that question with a “No,” primarily because they react to identity labels and gender atypical expression rather than to the question or the needs. The answer “Yes” may raise more questions than answers for those in ministry, and we discussed those at length with those in attendance. I would say by far most of the people we worked with wanted to answer “Yes” to that foundational question.

If one of the most frequently asked questions that is under the surface is, “Do you want me here?,” what are some of the common needs and other questions that may arise? I think the needs include a need for intimacy – to be known and to know others. A need for community. A place to land and belong. A place to explore questions about faith and God. “Does God love me?” and the more emotionally loaded question, “Does God like me?” Of course, these are questions many youth are asking. The questions become more complicated for those navigating sexual and gender identity questions, particularly if they have reason to believe they will be rejected by Christians.

Those providing ministry will not have an opportunity to minister to these questions and needs that are under the surface if their primary point of reaction is to what is going on above the surface. That doesn’t mean that identity labels and gender expression are unimportant. But a hypervigilance these things can create a set of conditions that may not reflect your heart and vision for ministry.

Even well-intended, seasoned ministry folks face the additional challenge of creating a ministry climate that reflects their heart and vision to minister to what is beneath the surface.

A youth minister once shared with me how he was trying to reach LGBT+ youth in his community. He was trying to be missional in his approach. A missional approach looks  like this: Belong – Believe – Become. This is in contrast to models that focus on Behave – Believe – Belong, in which behavioral compliance is communicated on the front end and is ultimately a condition for belonging. (This is not original with me; I discuss it and the source in Understanding Gender Dysphoria.)

So this youth minister was working on a missional approach in which all young people would be welcomed (belong), and in which all would have an opportunity to learn about Christ (believe). Only later would ministry focus on discipleship with a focus on Christlikeness (become). He then has to think deeply and well about what it means to become more Christlike and navigate sexual identity and gender identity questions.

One evening as they were getting going in youth group, a visitor to the group came dressed in androgynous attire and it was unclear whether the person was male or female or transgender. The youth minister struck up a conversation and was making an initial connection. But this is a large youth group, and he was pulled away to attend to an admin issue that arose for programming that night. He was gone for literally 3-4 minutes. In that time, a group of guys from the youth group went up to the visiting teen and made derogatory comments about the person’s attire and joked in a way that set the message (apparently), “You aren’t really in the right place.” The teen was gone when the youth minister returned.

There are two recommendations here. First, my encouragement to those in ministry is to think of the analogy of the iceberg. To react not to what is presented above the surface but to take time to explore what may be beneath the surface. A second recommendation is to develop a ministry climate that reflects your vision. This includes training adult volunteers and key students in what you are trying to do and how, so that they understand their role in key moments of hospitality. This is especially important insofar as you may wish to take a more missional approach to people who may be curious about faith and have normal, fundamental needs regarding intimacy and community.

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.

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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.

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.

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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.