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.

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.

Transgender & Gender Variant Youth

flower-in-stonesOver the past two years I’ve been speaking with colleagues at the National Youth Worker’s Convention. This past year I was speaking with Julie Rodgers who works in the chaplain’s office at Wheaton College. We typically co-present a 5-hour intensive, followed by a 1.5 hour breakout workshop and a 30 min interview at the Idea Lab. It has been interesting to reflect on the Frequently Asked Questions (FAQs) that come up in these settings. What are youth ministers really dealing with? What questions do they have? When we conducted a recent study of youth ministers, we did hear interest in learning more about theories of causation and change; however, we asked if they were interested in those questions. What I find interesting is to conduct a workshop and hear what those in attendance actually have on their minds. We did receive a couple of questions like that, but I would say that one common and fascinating theme was actually not about homosexuality or sexual identity. It was about transgender issues and gender variant behaviors.

The question would be something like this: “Our youth group frequently breaks up into smaller groups with guys in one room and girls in another. Well, we recently had a teen visit our youth group who was born male but identifies as female. This teen’s preference is to break out with the females. What should we do?”

The prevalence estimates on transgenderism put it at quite a bit less frequent than sexual identity based on self-report of attractions, behavior, or even identity labels. As we discussed it afterward, it may be more of a reflection of the anxiety of the presentation than the actual frequency of the presentation. However, in one session, this was the actual question asked, so it has occurred in at least one of the youth groups represented at the conference.

I resist the temptation to offer “three easy steps” to navigating gender identity questions that arise in youth group. Transgender and gender variant presentations are going to be a challenge for the church moving forward. It is clearly going to be the next cultural wave that will crest soon over conventionally religious people in a way that will stretch them to think through their own views of the topic, how best to create a place for young people who are navigating that terrain, and how they wish to relate to a broader culture that does not support their presuppositions.

There is a calculus that is involved that is difficult to calculate. One the one hand the Christian community wants to be able to affirm male and female distinctions rooted in the creation narrative and thought to be part of a larger theological anthropology. Evangelical theologians tend to cite these distinctions as important for a Christian ethic centered on both sexual behavior and gender identity, although these are two different discussions in some important ways.

OLYMPUS DIGITAL CAMERAHaving acknowledged the challenge, let me say that youth ministers want answers. What do we do? This is part of the reason why I am drawn to speak at these events. No fluff. I think the most thoughtful accounts from the Christian community will balance both teaching and ministry; theology and pastoral care–in a cultural context that will increasingly not share an identical point of reference with respect to sex and gender norms. As I said to the group in attendance, I don’t have a list of what you should do. I would fall back on a more careful assessment of what is being presented and what is being requested. And churches vary considerably in how they intend to approach divisive topics, how they relate to their local community, and so on. These differences are due to location, theological assumptions, personnel, and key stakeholders. For example, I know of many churches in southern California, for instance, that are trying to be missional in their attempts to accommodate a range of requests that might come from transgender and gender variant persons. Certainly if your youth group is taking that posture in the context of a larger church that has more of a missional approach, such a stance will inform your options and interests in that moment.

A little background: transgender is an umbrella word for many ways in which people might experience themselves as different than those who biological sex and gender identity correspond to establish a kind of congruence. A person could have a strong cross-gender identification with a desire to cross-dress; some may cross-dress to manage dysphoria while others to express their sense of self; still others might experience their gender identity as residing along a continuum rather than a cross-gender identification (a person might think of themselves as genderfluid or genderqueer). Those who are transgender who experience significant gender dysphoria have a serious condition that would likely have brought them under the care of a mental health professional (and possible multidisciplinary professional team including medical professionals). This condition is quite rare and I would want to seek some consultation from those who are working closely with the teen who is demonstrating a preference for one break out group over another (or whatever the question is that we are discussing).

So the place to begin is actually not in offering a definitive answer to where the person should go during a breakout. A place to begin might be, How well do you know the person and how do you best understand the request in the context of your larger mission? That will require a relationship–a sustained relationship in which discussions take place about the experience navigating gender identity questions or concerns. I could imagine working out different solutions with different youth given a number of potentially important variables. Do those in ministry (and parents who support them) have the patience for that kind of ministry care? I hope so. If the church hopes to provide a place for young people to navigate difficult issues in a changing culture, we will have to be rather thoughtful and mature in our responses.

For those who are interested:  I have been working on a book on the topic of transgender and gender variant persons that is due out in 2015. It has been fascinating to conduct background research in this area, as well as to draw upon clinical experiences over the years. I hope it will at least provide information and an integrated framework that will inform how a youth minister or pastor responds to transgender and gender variant people in a culture that is changing in terms of attitudes toward sex and gender norms and presentations. I’ll do a few posts on the topic as we get closer to the release date.

 

Developmental Trajectories among Gender Dysphoric Children

sextherapytextInterVarsity Press Academic and the Christian Association for Psychological Studies are set to publish a new book I wrote with Erica S. N. Tan titled, Sexuality & Sex Therapy: A Comprehensive Christian Appraisal. I am hearing it will be out in April.

After four foundational chapters offering theological, sociocultural, biological, and clinical perspectives on sexuality, we discuss several sexual dysfunctions, the paraphilias, sexual addiction, and other clinical presentations. Here is an excerpt from the chapter on Gender Dysphoria.

What we are discussing is onset and course. Specifically, we are discussing a study of children who persist and desist in their experience of Gender Dysphoria:

Although there is relatively little research on gender dysphoria as compared to many other sexual concerns, there has been some preliminary research (Steensmaet et al., 2010) on possible developmental trajectories among those who persist (in their experience of gender dysphoria) and those who desist (or who do not continue to experience gender incongruence).

When these two groups are compared, it is interesting to note that there are apparent differences in underlying motives in cross-identification, as well as differences in responses to changes at puberty. In considering motives for cross-identification, one persister shared the following: “In childhood (and still), I had the feeling that I was born as a boy. I did not ‘want’ to be a girl. To myself I ‘was’ a boy, I felt insulted if people treated me as a girl. Of course I ‘knew’ I was a girl, but still, in my view I was not” (Steensmaet et al., 2010, p. 6). In contrast to this, a desister shared this: “I knew very well that I was a girl, but one who wished to be a boy. In childhood I liked the boys better, the girls were always niggling [petty, nagging]. I was tough and wanted to be as tough as the boys” (p. 6).

When the researchers looked at the different responses to puberty, they noted the strong reaction against these changes among those who persisted with their gender incongruence. One persister shared the following: “It was terrible, I constantly wanted to know whether I was already in puberty or not. … I really did not want to have breasts, I felt like, if they would grow, I would remove them myself. I absolutely did not want them!” (Steensmaet et al., 2010, p. 8).

Again, in contrast, a desister shared this: “Before puberty, I disliked the thought of getting breasts. I did not want them to grow. But when they actually started to grow, I was glad they did. I really loved looking like a girl, so I was glad my body became more feminine” (Steensmaet et al., 2010, p. 12).

Keep in mind that both groups engaged in some cross-identification at a young age, about 6 or 7 years old. However, Steensma et al (2010) reported that for those who desisted—whose gender dysphoria abated over time—that change occurred at between 10-13 years of age, whereas the gender dysphoria seemed to increase for those who were called persisters.

The persisiters would go on to disclose and make a plan for some kind of transition between the ages of 10-13 years old, while those who desisted tended to identify with their birth sex at age 13 and older.

Although I have provided clinical services and consultations in the area of gender dysphoria and have conducted research involving transgender Christians, I have not written that much about it. I enjoyed the opportunity to work on this chapter with Erica and to reflect further on gender identity and gender dysphoria from a Christian worldview.

National Transgender Day of Remembrance

Today is the National Transgender Day of Remembrance. It is a day set aside in November to remember people who have been killed for being transgender. “Transgender” is itself an umbrella term for the many ways people experience their gender identity in ways that do not match what most people experience. Under this umbrella are experiences of gender dysphoria, in which a person feels incongruence between their birth sex and their psychological sense of themselves as male or female.

There is much that could be said about people who are navigating their gender identity. It is not a very common condition at all and deserves some thoughtful reflection and pastoral sensitivity. It is often confused and coupled with the topic of homosexuality in ways that makes it difficult for many Christians to understand.

Out of respect for the day, I am going to post a video that was made from portions of the documentary about Gwen Araujo.

I first showed the story about Gwen Araujo to a group of students who were enrolled in a multicultural psychology course. I was guest lecturing on these issues, and I wanted  them to have some exposure to the topic from a different perspective than they might otherwise have had. What I appreciated about it was how it tried to show the main character as a child and then through adolescence and into young adulthood. We went into other issues and reviewed research findings, etc., but the personal story should not be overlooked.

I think of people I have known–some clients and some personal friends and acquaintances. It has been important to me to think about the person as a child who experiences gender dysphoria as well as the challenges they would face at puberty and into and through their teen years. They are not choosing to experience this dysphoria; they find themselves facing this often at a young age. It is a very difficult experience to have and to try to navigate on one’s own and, today, in the context of a larger cultural atmosphere that can quickly detract from the kind of compassionate response that might otherwise be offered.

Part of what makes this difficult is that many in the church feel they are defending a biblical sexual ethic in the area of homosexuality, and it has been hard to separate these issues out in a way to engage in a thoughtful manner. This post is not intended to do that; I will get back to this topic at another time. I’ve been working on a book chapter on gender dysphoria, and I would be willing to share more of my thoughts in this area.

Today I wanted to acknowledge the day itself, the people who are navigating this difficult terrain, and the need for a thoughtful, faithful response from the church.