Understanding Transgender Identities

If you are interested in the topic of transgender experiences, you might want to pre-order a forthcoming book. The resource is titled, Understanding Transgender Identities: Four Views. Here is the description from the publisher:

This book offers a full-scale dialogue on transgender identities from across the Christian theological spectrum. It brings together contributors with expertise and platforms in the study of transgender identities to articulate and defend differing perspectives on this contested topic. After an introductory chapter surveys key historical moments and current issues, four views are presented by Owen Strachan, Mark A. Yarhouse and Julia Sadusky, Megan K. DeFranza, and Justin Sabia-Tanis. The authors respond to one another’s views in a respectful manner, modeling thoughtful dialogue around a controversial theological issue. The book helps readers understand the spectrum of views among Christians and enables Christian communities to establish a context where conversations can safely be held.

The book is scheduled for release November 5. You can pre-order today.

The Cultural Salience of Gender Dysphoria

As 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.

It’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

“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

Calvin 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.

As 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.

Developmental Trajectories among Gender Dysphoric Children

InterVarsity 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.

Gender Identity Issues

Here is an interesting video we are viewing in preparation for a training on Gender Identity issues at the Institute for the Study of Sexual Identity:

If you are curious about how we approach training, let me begin by saying we follow many of the leading mainstream LGBT researchers and theorists; they are the one’s doing the majority (by far) of the research. There are few Christians doing serious scholarship in this area, and to limit our understanding of gender identity, for instance, to just what is produced by Christian psychologists (or Christians from other disciplines), would put us at a severe disadvantage.

Some of the strengths of this video include exposing the viewer to the ways in which the word “transgender” functions as an umbrella term. We may say this all the time, but it can be helpful to “meet” various people who prefer different ways of describing themselves and their experiences, such as transman or female-to-male transsexual. There is also some interesting perspective offered on key terms, such as biological sex, gender role, gender identity, and sexual orientation. Just the discussion of the common ways people think of differences and the ways in which the folks in the video think of differences is informative. There are also some helpful suggestions on how to approach a person – how to talk with them in a way that would be respectful given how they experience themselves.

It would have been helpful to have additional information on developmental perspectives on gender identity, as well as information on some of the issues that lead people to seek counseling/therapy services. But that was not the purpose of the video; the video was meant to be introductory and essentially a primer.

You can imagine that there are many issues that arise for those interested in integration of a Christian worldview with the study of gender identity. I won’t be able to do them justice here, but there are important questions about the relationship between biological sex and gender identity, the nature of the Fall, and how best to respond to such concerns from either a mental health or pastoral care perspective.

Update: Transgender Christians’ Experiences

The paper presentation on “Transgender Christians’ Experiences: A Qualitative Study” was earlier today. It went well. Trista and I went back and forth and discussed the various responses we received to questions about personal faith, relationship with God, religious coping activities, issues that arise in marriage, employment, etc. The day before the session, we were able to arrange to have a person in as a discussant who is transgender and Christian. She shared some of her own story and the challenges she has faced and choices she has made in response to gender dysphoria. Of course, these choices are not without consequences, and she was also able to share how some of her decisions had an impact on family members, local church experiences, and so on.

Although the audience was not large, those in attendance showed a genuine interest in the topic, and some had provided clinical services to this population. Most of the questions actually went to our discussant, which made a lot of sense, as she was quite open and transparent in sharing from her experience, and many in attendance probably have had few opportunities to interact with and ask questions of someone who has been sorting out gender identity questions and conflicts.

I also appreciated the opportunity to present at the Virginia Psychological Association. I have tended to gravitate toward the national organization, and this was my first foray into the state association. The audience was great, and the people there were quite receptive to the presentation and seemed quite appreciative that the topic was covered the way it was.

Transgender Christians’ Experiences

This Thursday I’ll be co-presenting an interesting study I conducted with Trista Carr, a student in the Doctoral Program in Clinical Psychology at Regent. The study is interesting to me in part because it is the first one we’ve undertaken that has addressed the relationship between gender identity and religious identity. Specifically, it is a study of 32 self-identified Christians who also self-identified as biologically male but transgender. They provided information on their experiences with local churches, their relationship with God, their spouses, employers, and so on. They also shared ways in which religion was a coping resource. Some even shared how their struggle with gender identity concerns led to a strengthening of their personal faith as Christians.

Here is the abstract from the paper we’ll be presenting:

Though the experiences of transgender persons have been explored to some extent, very few scholars have delved into the relationship between gender identity as a trangender person and religious identity as a Christian. Therefore, the qualitative data described herein reflects the narratives of 32 transgender individuals who are biological males and identify as Christians. The study sought to bring some understanding of the events and processes that occur for this specific population. Although some participants indicated that their gender identity conflict led to a strengthening of their personal faith, others reported a past struggle – often with specific persons or church leadership – and some indicated that they moved away from organized religion in light of their conflict. Many participants in this study still identified religious coping activities tied to their faith tradition as sources of support during present difficulties. Participants also shared experiences with conflicts in their marriages and places of employment.

The study came about through a number of developments over the past several years. Some of those developments included providing consultations to families who were worried that their child might be gay. The children were often presenting with symptoms of Gender Identity Disorder, and some met criteria, while others had symptoms but were sub-threshold for the diagnosis. I’ve also worked with older adolescents and adults who identified as transgender and Christian and were asking for assistance with possible ways to manage their dysphoria and/or conflict with their religious beliefs and values. If you know someone who is transgender or if you’ve worked with this population, you may have a sense for how challenging it can be to fully understand the issues that are involved.

A few years ago I was also introduced by someone who identified as transgender and Christian to an online group of people with similar experiences. This led to the idea of possibly furthering my own understanding of their experiences (and the experiences of adults I’d worked with) by conducting an initial study of some of what they had been dealing with. I brought this idea to the Institute for the Study of Sexual Identity (ISSI), the research institute I work with at Regent, and Trista expressed interest in working on it, as did some of our other team members. So we got to work on developing a questionnaire, and we ran it by various members of the community for help with wording, etc. We announced the study through various avenues, and people were able to access it online and provide us with some of their experience with gender and religious identity issues. So the study is a first step, and I hope we are able to follow it up with additional studies that delve into other related areas, but it is a start.

The paper we’ll be presenting is titled, “Transgender Christians’ Experiences: A Qualitative Study.” It will be presented at the Virginia Psychological Association’s (VPA’s) spring convention this Thursday, April 22, from 4-5pm at the Norfolk Waterside Marriott.