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.

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 – 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.

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.

Legislation Regarding Gender Dysphoria

Boy Girl signpostFinished up an interview today for a Christian magazine that is working on a story on gender dysphoria. The story was prompted by recent legislation that is being voted on in California. The legislation would “ensure students could participate in school activities and use facilities like bathrooms based on their gender identity, not their physical sex,” according to the LA Times. Here is the key text from the legislation:

Existing law prohibits public schools from discriminating on the basis of specified characteristics, including gender, gender identity, and gender expression, and specifies various statements of legislative intent and the policies of the state in that regard. Existing law requires that participation in a particular physical education activity or sport, if required of pupils of one sex, be available to pupils of each sex.

This bill would require that a pupil be permitted to participate in sex-segregated school programs, activities, including athletic teams and competitions, and use facilities consistent with his or her gender identity, irrespective of the gender listed on the pupil’s records.

Another story coming out of Oregon raises similar questions about access to facilities. In that story, six bathrooms were converted to unisex restrooms. This resolution seemed to meet the concerns of multiple stakeholders, as many families might not be comfortable with where the CA legislation is heading, while at the same time there is a desire among many families to respond compassionately to the needs of the person who experiences gender dysphoria. In any case, the conversion of six bathrooms to unisex restrooms was viewed by the transgender teen featured in the article.

In the interview I participated in, I didn’t really get into a discussion about legislation. I think that is an area where we need wisdom in thinking through how best to respond so that Christians are not reducing the complexities to just how to defend one’s beliefs/values in a culture war. While there is a need to defend religious liberties, there is also a need to respond to a range of issues that arise in these discussions. Unfortunately, when these complex issues are handled through legislation, my experience is that frequently no one comes out ahead. So we need to be wise about political issues while at the same time consider the experience of people who are gender dysphoric and the challenges they may face in a range of situations.

Back to the interview: I discussed what we know and do not know about gender dysphoria in terms of prevalence, etiology, and treatment, including controversial treatment options and current trends. We also discussed how Christians ought to respond from more of a clinical and pastoral standpoint, and I discussed humility and empathy for the family that is navigating gender identity concerns. We certainly do not want to drive them away from the church or contribute to shame (which is essentially self-condemnation that isolates itself from others for fear that if their experiences were know by others, they too would reject/condemn them).

In my role as a psychologist who provides consultation to individuals, couples and families navigating these difficult issues, I make sure that they are familiar with the current state of the research, including what we know and do not know in the areas mentioned above (e.g., etiology). I also want them to know what options are available to them at the present time and in the years to come. I also talked about working with the gender dysphoric person and his or her local church in terms of providing education and encouraging a supportive and sustained presence in the life of that person (and his or her family), as well as providing mature spiritual guidance.