What is Gender Dysphoria?

Here is a talk I gave at Q Denver titled, What is Gender Dysphoria?  It is being featured on Q Ideas. I try to explain the phenomenon, as well as provide a little background information on theories of etiology, prevalence, and management strategies. Also, check out the talk by Melinda Selmys, who shares about her own experiences with gender dyshporia.

After we both spoke, Gabe Lyons invited us to join him for a time to Q & A from the audience. This was a helpful opportunity to reflect further on gender dysphoria:

To give you a little background on Q Ideas, here is a description from their website:

Q was birthed out of Gabe Lyons’ vision to see Christians, especially leaders, recover a vision for their historic responsibility to renew and restore cultures. Inspired by Chuck Colson’s statement, “Christians are called to redeem entire cultures, not just individuals,” Gabe set out to reintroduce Christians to what had seemed missing in recent decades from an American expression of Christian faithfulness; valuing both personal and cultural renewal, not one over the other. Re-educating Christians to this orthodox and unifying concept has become central to the vision of Q.

Together, we explore topics that fall into four broad themes: culture, future, church, and gospel. Q facilitates the investigation of deeper engagement and responsibility in each of these areas. As we continue to work through these ideas on a deeper level, so grows our commitment to equipping innovators, social entrepreneurs, entertainers, artists, church-shapers, futurists, scientists, educators, historians, environmentalists, and everyday people to do extraordinary things. At Q Ideas, you’ll see a broad spectrum of content represented in our small group curriculum, essays, videos, blog articles, and podcasts. These are all contributed and commissioned to shed light on unique areas of culture and the church.

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.

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.

 

 

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.

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.

 

 

 

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.