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- Herausgeber: IVP Academic
- Kategorie: Fachliteratur
- Serie: Christian Association for Psychological Studies Books
- Sprache: Englisch
- Veröffentlichungsjahr: 2022
Helping people navigate gender identity questions today is complex and often polarized work. For clients and families who are also informed by their faith, some mental health approaches raise more questions than answers. Clinicians need a client-centered, open-ended approach that makes room for gender exploration while respecting religious identity. Gender Identity and Faith carves out clinical space for mental health professionals to help people who wish to take seriously their gender identity, their religious identity, and the relationship between the two. Drawing from their extensive research and experience with clients, Mark Yarhouse and Julia Sadusky provide a timely, practical resource for practitioners. This book - emphasizes respect for clients' journeys, without a single fixed outcome, toward congruence between their Gender Identity and Faith - describes effective clinical postures, assessment and therapeutic tools, and numerous case studies - covers needs and characteristics of children, youth, and adult clients - includes worksheets and prompts for clients and family members"Integrating personhood and values is no easy feat, especially in our current cultural landscape," the authors write. Those navigating this intersection need clinicians who seek to understand their unique context and journey alongside them with empathy. This book points the way. Christian Association for Psychological Studies (CAPS) Books explore how Christianity relates to mental health and behavioral sciences including psychology, counseling, social work, and marriage and family therapy in order to equip Christian clinicians to support the well-being of their clients.
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Contents
Preface
AS WE WROTE THIS BOOK, Arkansas became the first state to limit certain medical interventions—puberty blockers, hormone therapy, and gender-confirmation surgery (formerly called sex-reassignment surgery)—for minors (Cox, 2021). Many lesbian, gay, bisexual, transgender, queer, and other (LGBTQ+) interest groups have actively opposed this legislation, framing it as “anti-LGBTQ+” in its potential consequences for young people who are navigating gender identity or who represent a diverse gender identity.
According to a recent USA Today report, fifteen other states are considering similar legislation. The South Carolina bill under consideration, for example, would apply to any youth under age eighteen. This bill proposes to limit “gender reassignment medical treatment,” which it defines as the following health care interventions:
(a) interventions to suppress the development of endogenous secondary sex characteristics;
(b) interventions to align the patient’s appearance or physical body with the patient’s gender identity; and
(c) interventions to alleviate symptoms of clinically significant distress resulting from gender dysphoria, as defined in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition.1
Depending on which version of the legislation is adopted, professional and legal consequences could ensue for medical professionals who provide these interventions to minors (Lamb, 2020). Consequences could include professional discipline, loss of one’s license, fines, a charge of malpractice, and even a felony conviction. LGBTQ+ groups have responded by insisting that the medical coverage and care of transgender youth must be protected.2
While legislation like that passed in Arkansas and comparable bills being considered in South Carolina are at odds with the efforts of LGBTQ+ groups, other recent public policy decisions reflect the impact of LGBTQ+ advocacy. Legislation limiting gender-identity-change efforts (GICE) has been passed in as many as nineteen states and will likely continue to be introduced in other states. For example, New York’s legislation on sexual-orientation-change efforts (SOCE) also includes restrictions on “efforts to change behaviors, gender identity, or gender expressions.”3 New York’s legislation also clarifies that the limits it places on SOCE “shall not include counseling for a person seeking to transition from one gender to another.”
Like the anti-medical-transition legislation adopted in Arkansas and proposed in South Carolina and other states, this anti-GICE legislation also includes professional and legal consequences for those who violate restrictions. However, these consequences threaten a very different group of medical practitioners.
We do not intend by this brief glimpse of the landscape to imply that these two sets of legislation are equivalent. The major mental health professional organizations in the United States have weighed in on these discussions and are against SOCE and GICE. They have also weighed in against efforts to limit access to medical services that would support and facilitate transition.
The reason we cite these divergent perspectives is to underscore that we are at a cultural moment in which the care provided to minors who are navigating questions around their gender identity is under great scrutiny, frequently polarized, and hotly contested. When legislation is introduced on either side of these debates, it may be well intended, but it can have a chilling effect on actual practice, limiting who is willing to work with people navigating gender-identity questions.
This book, then, is a timely resource for clinicians and others looking to gain awareness of the cultural, ideological, and political polarization surrounding care for young people navigating gender-identity questions. However, opinions and recommendations in this area are changing rapidly. We want to acknowledge that standards of care are subject to change over time, and no one book can possibly account for these possible changes in their totality. At the time of writing this, the World Professional Association for Transgender Health (WPATH) 2011 standards are in place, and these will inform our approach (Coleman et al., 2012). We recognize that changes in WPATH guidelines and updated research ought to lead to adjustments in conceptualization and treatment approaches. We are eager to learn alongside the field and will incorporate new information as it comes, knowing full well that we cannot fully predict and account for those updates here.
With that caveat in mind, the approach taken in this book reflects years of clinical experience that became more formalized after a special panel convened by the American Psychological Association (APA) to provide recommendations to the Substance Abuse and Mental Health Services Administration (SAMHSA) on SOCE and GICE with minors. One of the panel’s recommendations was to help youth explore their gender identity without a “fixed outcome” (SAMHSA, 2015). This proposal was meant to guard against two sets of concerns facing the consensus panel. In one direction, the panel wanted to caution against relying on gender stereotypes to discipline a child toward resolving gender conflicts with their natal sex. In the other direction, the panel was concerned about premature transitioning without sufficient gender-identity exploration or amelioration of coexisting mental health concerns.
Although many transgender-affirming resources are available today (and more will undoubtedly be made available in the years ahead), some of these approaches raise more questions than answers for conventionally religious families whose religious doctrines and values, including religious norms regarding sex and gender, inform their decision making.
As we were writing this resource, we were faced with the question of language and terminology usage for sex and gender. We want to take a moment to share with the reader our perspective on language, because how we discuss the topics and the terms used is important. We tend to use the term natal sex (or natal male or natal female) to refer to the sex of a person at the time of their birth, their biological sex, or what is now sometimes referred to as their sex assigned at birth or sex designated at birth. The latest version of the APA Publication Manual (7th ed.) recommends writers avoid terms such as biological sex or natal sex in favor of “sex assigned at birth” or “sex designated at birth.”4 The Publication Manual voices the concern that reference to biological or natal sex can be viewed as disparaging by some scholars in this area and by some members of the transgender community. These terms imply “that sex is an immutable characteristic without sociocultural influence.” We want to be respectful and mindful of how different people may respond to different terms and model that in our writing as well.
Conventionally religious persons are a subset of the population who are more likely to view sex as an immutable characteristic (whereas gender may be more subject to sociocultural influences). We certainly need to be aware of how language may be experienced by different transgender and nonbinary persons and their support people and adapt language accordingly. Because this resource is for practitioners who work with conventionally religious families, we encourage clinicians to be thoughtful and nimble in their use of language with this population and to account for intersecting identities that ought to inform their language. As a result, we use mostly “natal sex” and at times “gender assumed at birth” in this book to reflect the challenges with language and terminology and to underscore for the reader the need to be flexible in working with conventionally religious families and children, adolescents, and adults who are navigating gender identity and faith. In this book, the language preference is context specific to illustrate the flexibility that may be helpful in responding respectfully to the person sitting in front of us, and if an individual is troubled by the use of a particular term, it can allow for robust dialogue among family members, growth in empathy, and adaptations in language when indicated.
Clinicians need a client-centered, open-ended approach to care that makes room for gender exploration while respecting conventional religiosity. Such an approach must be flexible enough to aid family members who perceive matters of gender identity and religious identity differently. It must provide clinicians with ways of thinking about gender identity and religion in order to help them serve families for whom these experiences are particularly salient.
This resource carves out clinical space for mental health professionals to help people who wish to take their gender identity seriously, to take their religious identity seriously, and to take the relationship between their gender identity and religious identity seriously. It is designed for practitioners working with clients who wish to explore their gender identity in ways that position them (and, in the case of minors, their parents) to pursue congruence between their gender identity and their faith.
Acknowledgments
WE ARE UNABLE TO THANK BY NAME the countless members of the institute whose research informs our approach. We want to begin by acknowledging the work that went into our initial workbook, Gender Identity Journeys. With the help of Dr. Trista Carr and Dr. Emma Bucher, we developed this workbook to aid clients in the exploration of some aspects of their gender identity and faith. We also want to thank Caryn LeMur, who offered several suggestions, some of which were incorporated into that resource. The workbook was recently revised with the assistance of members of the Sexual and Gender Identity Institute, especially Chuck Cruise, whom we would also like to particularly thank for his contributions. Some of that material was initially presented in chapter six of Understanding Gender Dysphoria and was retained and expanded on here.
We could not have developed this present resource without the help of Dr. Gregory Coles, who offered careful assistance with editing and feedback early in the writing process. We also benefited from the feedback of several licensed psychologists, including Dr. Laura Edwards-Leeper, an internationally recognized expert on transgender and gender-diverse youth, and Dr. Diane Chen, Behavioral Health Director for The Potocsnak Family Division of Adolescent and Young Adult Medicine at the Ann & Robert H. Lurie Children’s Hospital, both of whom offered wisdom and critique that have helped us develop this resource in its present form. Thanks also to Ethan Martin for his work on the index.
Above all else, we are forever grateful for the countless individuals, families, and couples we have met with who bravely shared their gender-identity journeys with us. Whenever a story is shared in this book, the names and some details have been changed to protect their anonymity. Their diverse experiences are each worth sharing, learning from, and taking seriously as we approach such complex and important clinical work.
Abbreviations
AAP
American Academy of Pediatrics
APA
American Psychological Association
ASD
autism spectrum disorder
DBT
dialectical behavior therapy
DSM
American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders
GCS
gender-confirmation surgery
GICE
gender-identity-change efforts
GRIT
Gender and Religious Identity Therapy
HT
hormone therapy
LGBTQ+
lesbian, gay, bisexual, transgender, queer, and other
SAMHSA
Substance Abuse and Mental Health Services Administration
SOCE
sexual-orientation-change efforts
WPATH
World Professional Association for Transgender Health
Michael and Micaela are a married couple in their late thirties. They have a five-year-old child, Xavier, whose gender-atypical mannerisms and interests they describe as “different.” They are Christians and concerned about the best way to respond to and support Xavier.
Dani is a twenty-one-year-old natal female who reports distress associated with her gender incongruence. She is asking for help navigating gender-identity concerns in light of her spiritual beliefs. She has been isolating from her church friends, who all volunteer at the youth group there, for fear of what they would think if they knew about her difficulties.
RJ is a fifty-five-year-old natal male who has been married for thirty years. He and his wife, Kathy, identify as Christians. RJ reports he has been wrestling with his gender identity throughout their marriage and before they were married, and now that their children are out of the house, he reports a pressing desire to transition to female.
Evie is a twenty-nine-year-old single mother of two. Her youngest, Chris, is ten years old. Chris has made a social transition at home and at the local elementary school. Evie has called the church office to inform the church that Chris will present as a girl in the fall and that she wants Chris to be able to participate in children’s ministry accordingly.
Karen and Henry are a newly married couple in their late twenties. Henry has struggled with gender dysphoria since childhood, but the intensity of the dysphoria has ebbed and flowed, reaching its peak two years into their three-year marriage. The couple are high school sweethearts and the best of friends, but they are wrestling with the future of their marriage, given how distressing Henry’s dysphoria has become and how much he longs for hormonal treatment. They believe marriage is a covenant, which makes it difficult to know where to go from here in light of their faith.
Matt and Lisa have four children, and their youngest, Jonah, just turned eight years old. They have noticed that Jonah frequently wears his older sister’s dress clothes and asks Lisa when his hair will be long like hers. Jonah sometimes wakes up at night crying, saying, “I prayed that God would make me a girl, and he won’t listen to me.”
This book is addressed to mental health professionals with questions about providing services to conventionally religious clients whose gender identity does not correspond to their natal sex nor their gender assumed at birth. You may be reading it because, like many health care professionals, you have experienced a recent increase in referrals of such cases. The six cases with which we have opened this chapter reflect just a few of the many diverse gender presentations we have seen in our practices.
This book is not written to Christian counselors specifically; rather, it is intended for a broader audience of mental health professionals, including Christians, who find themselves working with individuals, couples, and families who are conventionally religious and whose religious faith is an important consideration in navigating gender-identity questions.
A book like this is important because the clinical and broader societal landscapes have become incredibly polarized around the very existence of transgender and other diverse gender identities. Disputes abound over the best way to care for people navigating gender identity and—in the case of this book—the intersection of gender identity and religious identity.
In this chapter we want to offer a snapshot of not only the kinds of cases we see in practice but also the current trends and controversies in care, as well as the general parameters of our approach. Note that several things distinguish our approach from existing approaches, including that (a) we do not focus on changing gender identity, and (b) we do offer concrete and specific strategies for exploring conflicts of gender identity and religious identity.
Our specialty is helping individuals, couples, and families who take their religious faith seriously, who take the questions they have about their gender identity seriously, and who take the relationship between their religious identity and gender identity seriously.
Of course, not everyone who comes to our offices asking for help is navigating gender identity and faith. Here are some of the other clients we have seen for a range of concerns:
Shannon is a male-to-female transgender person who is asking for treatment for panic attacks that keep her from performing at her job.
CJ is a natal male who is planning to transition in the next year. The decision has been made and is not up for discussion. CJ is asking for help crafting a letter to communicate this decision to adult children.
Kris is a nineteen-year-old natal female who describes themselves as gender nonbinary and prefers they/them pronouns. Kris is requesting help with improving family relationships with their family, none of whom identifies as religious.
Artie is an eighteen-year-old who just graduated high school and expresses interest in a social transition to female. Artie does not identify as religious and elects not to have religion be a part of the clinical services provided.
Some of our clients come to us simply asking for help addressing symptoms of depression, anxiety, or any number of other challenges. In these cases, the fact that the client is transgender is an important demographic variable, an individual characteristic, but gender identity is not directly significant to why the person is seeking clinical services. Other clients experience symptoms of depression or anxiety stemming from other people’s responses to their gender-identity questions, including experiences of discrimination, microaggressions, family conflicts, or peer rejection. In other words, these clients may not themselves experience a conflict between their gender identity and faith, but they are navigating relationships that are important to them, and some of these relationships may have been strained due to the client’s exploration of gender identity. We will touch on these kinds of relationships in this book, but they are secondary to our primary focus, which is to help individuals navigate religious-identity and gender-identity questions when such questions present tensions for them.
FOCUS OF THIS RESOURCE
The purpose of this book is to serve as a resource specifically to clinicians who work with conventionally religious clients and families for whom religious dimensions appear to be in conflict with their gender-identity questions. That is, the client (or, in some cases, the family) is navigating gender identity and faith identity and is asking for assistance in making sense of the relationship between these two salient aspects of experience. As we noted above, a secondary emphasis in this book is helping clients navigate relationships strained by differences in beliefs and values about gender identity and faith.
We have come to understand the great difficulties that can arise for those who pursue therapy to resolve such conflicts. Many individuals have come to us after pursuing therapy with other providers, having found these providers’ techniques to be irrelevant or outright damaging. In some cases, a therapist has underappreciated the significance of the client’s beliefs and values, encouraging them to leave behind their religious or spiritual convictions and questions in order to become a healthy and whole person. In other cases, a therapist has encouraged stereotypical gender roles in a way that increased feelings of shame and ultimately heightened the conflict the client felt. Still others have avoided therapists altogether, for fear that being known with regard to their gender identity would put them in so great a conflict with their sense of self, their faith community, or God that they cannot see a way forward.
THREE MEANING-MAKING STRUCTURES
Yarhouse’s previous work (2015) introduced the idea that there are at least three meaning-making structures or explanatory frameworks that represent different ways people understand diverse gender identities. These frameworks function as lenses through which people see the topic of gender identity today. The three lenses are the integrity lens, the disability lens, and the diversity lens. These lenses can represent unique conflicts that may arise between religious identity and gender identity and have been helpful points of reference in consultations and counseling.
In our work with conventionally religious families, the integrity (or sacred) lens has been the primary lens through which at least some family members understand sex and gender. This lens is based on widely held, traditional understandings of male/female difference that reflect sex and gender norms. The lens perceives certain inherent differences between how males and females ought to behave, what one theologian (Gagnon, 2007) refers to as an “essential maleness” and an “essential femaleness.” To violate these categories of essence is, according to the integrity lens, to violate the ethics of gender.
The disability (or departure) lens views gender-atypical behavior as a departure from the norm. When a person experiences incongruence between their natal sex and gender identity—where the vast majority of people experience congruence—that person’s incongruence represents a difference or variation from what is expected. Many people who adopt the disability lens believe this difference indicates that something is not functioning as it should. This lens does not imbue the lack of congruence with moral significance in the way that the integrity, or sacred, lens does. However, it still implies concern over the lack of congruence. This concern tends to manifest in empathy for the experience of incongruence, rather than seeing it as an ethical violation in need of correction.
The diversity lens is the lens depicted in most popular entertainment, media, and so on; it is the lens toward which much of Western culture is rapidly moving. This lens views gender incongruence not as a concern to be corrected (integrity) or as a condition to sympathize with (disability) but as a difference in experience that reflects a different kind of person. The diversity lens calls for more celebration of the variation among gender experiences and expressions. Some of the most vocal advocates of the diversity lens call for the deconstruction of sex and gender norms because these norms are sometimes considered oppressive.
We will talk in subsequent chapters about how best to think about and discuss these lenses when providing consultations or ongoing counseling services to individuals and families navigating gender identity. You can also discuss with clients ways in which they might draw on the strengths they see in different lenses to support an integrated lens of some kind. For now, we simply want you to be familiar with the lenses and begin to think through how each lens reflects different points of tension for people navigating gender identity and religious identity.
Regardless of people’s past experiences of therapy, it is integral to appreciate the power of a safe therapeutic relationship for those navigating gender-identity concerns. They are at a particular intersection of conflict, where beliefs—whether their own or their family’s—and lived experiences present a unique challenge to overcome. Integrating personhood and values is no easy feat, especially in our current cultural landscape. Those navigating this intersection are often misunderstood both by people who do not identify with a faith tradition and by people within their faith communities. They are in need of clinicians who can journey with them without a fixed outcome. Our hope is that this book can aid that process.
IN THIS CHAPTER OUR GOAL is to help clinicians ask relevant questions to get an accurate account of their clients’ religious beliefs and values, gender-identity development, and any conflict clients may experience between their religious and gender identities. We will distinguish between assessment of children and assessment of adolescents/adults since this is a common distinction in the literature.
CULTURAL HUMILITY & ASSESSMENT
As Hopwood and Witten (2017) remind mental health professionals, it is important that we clinicians become aware of our own beliefs and values and potential biases so that we are able to assess culture, beliefs, and values and incorporate multiple aspects of diversity, including religious and spiritual issues, in therapy in a respectful and competent manner. Our ethical obligation is to work actively to eliminate or significantly reduce the effects that biases can have on our work and to foster deep respect for the cultural and individual variables at play. In fact, practice guidelines explicitly discuss the influence of religion and spirituality on the decisions people make regarding gender identity, as well as access to resources, level of stress, resilience, and coping. This too offers a clear emphasis on taking seriously the intersection of cultural identities and exploring the “salience of these aspects of identity” in an ongoing way (American Psychological Association [APA], 2015, guideline 3).
Keep in mind that it is beyond the competencies of mental health professionals to adjudicate theological positions of major world religions or to prescribe a fixed way of integrating these positions into personal beliefs and values. Respect for the rights of individuals to self-determination is central to the mental health field. However, clinicians can speak to the mental health correlates of lives informed by or shaped by various teachings, as well as to some of the challenges in navigating gender identity and religious faith. Indeed, it is important to identify our own biases about religion as they arise. Clinicians will benefit from acknowledging that we cannot fully understand any individual’s particular experience. Thus, clinicians do well to invite clients to correct us insofar as we misunderstand, misrepresent, or devalue their religious/spiritual beliefs and other aspects of culture for them or those of their family. This is an important starting point as we enter into assessment of religious identity, gender identity, and exploration of the intersection of these and other aspects of identity in those we meet with.
In our clinical work, we have found that many clients are wary of mental health professionals for fear of their beliefs and values or their own experiences of gender identity being villainized, pathologized, or otherwise disregarded. Rapport building is best accomplished when these tensions and concerns are addressed overtly as part of the assessment process; this goes far in highlighting the dedication to ethical care for those we serve. Honest rapport and mutual understanding in the assessment process is most likely in the context of building trust and a nonjudgmental openness to the particular and nuanced experiences of individual clients and families.
There are important nuances to consider when it comes to working with gender minorities across different racial and ethnic groups. The Williams Institute at UCLA reported that 0.6% of the adult population identify as transgender. They estimate that 0.8% are African American or Black, 0.8% are Latina/o or Hispanic, 0.5% are White, and 0.6% are of another race or ethnicity. Additionally, in the U.S. Transgender Survey, 62% of participants identified as White, 17% as Latina/o, 13% as Black, 5% as Asian, 3% as multiracial, less than 0.1% as Native American, and less than 0.1% as Middle Eastern (Flores et al., 2016, p. 7).1 Of note, people of color “experience deeper and broader patterns of discrimination than white respondents and the U.S. population” as a whole, including increased likelihood of living in poverty, being unemployed, and living with HIV (James et al., 2016, p. 6). This further highlights the diversity among transgender people and the importance of attending to the intersection of various aspects of identity as they relate to quality of life, risk factors and strengths, goals for therapy, and so on. Exploration of ethnic identity as well as its interaction with religious identity can also help us unearth both challenges and resilience factors for different individuals who come to therapy around gender identity, and we would be remiss if we didn’t highlight this early on in the explanation of our approach.
ASSESSMENT OF RELIGIOUS IDENTITY
Most of the individuals and families who seek counseling from us at the intersection of gender identity and religious identity consider themselves highly religious. Understanding the precise nature of these religious beliefs and values is crucial to evaluating the conflict people may experience with their gender identity (or that of a loved one). Clinicians must assess religious identity, then, because a person’s religious and spiritual beliefs will shape their response to their own gender experience or that of a loved one.
Psychologists have developed measures for many aspects of religion and spirituality in a person’s life. Clinicians can consider measures of (a) religiosity/spirituality (e.g., spiritual well-being scale), (b) functioning and faith (e.g., religious problem-solving styles), (c) God concept or one’s emotional experience of God, (d) religious orientation (e.g., extrinsic religiosity), and (e) measures of one’s personal experience of God (Hall et al., 1994).
Any number of these measures could be used to aid in the assessment of religious identity in a person’s upbringing and family. The spiritual genogram, for instance, has been used by many therapists to obtain information about a family’s religious and spiritual beliefs, values, and heritage (Hodge, 2001). Our focus should be on reaching a better understanding of the client’s or the family’s religious faith tradition, especially in relation to sex and gender norms, gender identity, and gender expression. We have found that even in cases where a young person navigating gender identity does not subscribe to their family’s spiritual beliefs, that person’s gender identity exploration could be impacted by messaging they received about gender while they were growing up.
Assessment of children. When we provide a consultation to a family with a young child, we assess the family’s religious and spiritual background, as well as the extent to which their religious beliefs and values inform their response to their child’s gender expression today.
When we meet with parents, we ask them whether religious or spiritual faith is a part of their current way of being in the world. As we noted above, a family’s religious and spiritual identity is often why they are coming to see us rather than going to another specialty clinic, even when we have offered a referral to a larger, more comprehensive specialty clinic.
Because religion is often salient in the lives of the families we work with, we ask parents about the religious faith traditions they were raised in (broadly), as well as the local religious faith communities they have participated in (narrowly). We ask them how much of the faith they were raised in is a part of their life today, or how much it has informed the raising of their children, regardless of their current practices, using inquiries like the following:
Tell me about your religious faith tradition growing up.
How were your religious beliefs and values expressed in your home growing up?
How much of the religious faith tradition you were raised in is a part of how you view things today?
We then move our assessment toward the questions these parents are raising about a loved one’s gender identity. We ask how the faith they adhere to today addresses questions that arise around sex and gender.
As you think about your religious faith tradition now, what have you found it teaches on sex and gender?
How do teachings from your religious faith community inform your understanding of sex and gender?
How do teachings from your religious faith community shape your response to your child?
Assessment of adolescents/adults. When we provide a consultation to a family with an adolescent—that is, any person between the ages of ten and nineteen—we assess the family’s religious and spiritual background in much the same way we assess a family’s background when they present to us with a young child.
When we assess an adolescent, however, we also ask the adolescent about the religious tradition they are being raised in (broadly) and their experience in their local community of faith (narrowly). That is, we want to have a better understanding of their experience in the Southern Baptist denomination, for instance, as well as what it has been like for them to be a part of Redeemer Church, for example.
As we do when we interview parents, we want to ask the adolescent how much of the faith tradition they were raised in informs their beliefs today. If they distance themselves from the family faith tradition or reject it outright, it may be helpful to understand what led them to that decision and whether that decision was related in any way to the tradition’s teachings on sex and gender.
Can you share a little about your religious faith community growing up?
How much of the faith tradition you were raised in is a part of how you view things today?
Can you share a little about what your religious faith community teaches about sex and gender?
How have those teachings about sex and gender been communicated to you—either at your place of worship or at home?
Which aspects of the teachings about sex and gender from your faith tradition are important to you today?
ASSESSMENT OF GENDER IDENTITY
Assessment of children. The field is not in agreement about the best way to evaluate children’s gender identity, and we see a range of models being used at different specialty clinics. Berg and Edwards-Leeper (2018) provide a helpful overview of some of these different approaches. They highlight the general shift in the mainstream of the field away from assessment questions and measures that assume a pathology model and toward approaches that frame gender identities in terms of diversity. These now-prevailing approaches distinguish common gender exploration and gender-diverse experiences from gender dysphoria as it is currently understood in contemporary nosology.
Broadly speaking, this shift in the field is a move toward what is sometimes referred to as “gender affirmative assessment” (Berg & Edwards-Leeper, 2018, p. 103). Like previous assessment models, gender-affirmative assessment can include interviews with parents and the child, play therapy with the child, and psychological batteries that measure cognitive functioning or are otherwise intended to rule out possible co-occurring mental health or behavioral issues. Regardless of which methods are used, gender-affirmative assessments seek to move away from traditional, normative assumptions about gender development and toward more open, child-centered approaches that reflect an expanded vista for gender, gender expressiveness, and diverse gender identities.
When families approach us for a consultation, we inform them of other more comprehensive specialty clinics that are multidisciplinary and might offer a range of approaches to gender-identity assessment. However, many of our referrals desire to navigate gender-identity questions as individuals or families in ways that are sensitive to their religious beliefs. They have sometimes chosen to come to our clinic after seeking services elsewhere and finding the assessment process to be hasty, feeling that their beliefs have been dismissed or undermined. A failure to assess religiosity, and how religion and spirituality interact with beliefs about gender, highlights again the importance of cultural humility; clinicians must attend to religion and spirituality as important diversity variables among those we work with.
We describe our approach to gender-identity assessment as balanced, client-centered, and without a fixed outcome.2 It is balanced because we locate ourselves between two more extreme positions: (a) those who are critical or dismissive of transgender and gender-diverse experiences and (b) those who, in an effort to be affirming of transgender and gender-diverse experiences, may do so without sufficient regard for contextual and other issues. We aspire to thoughtfully engage with the identified client and their family, recognizing that there are different lenses through which people see gender identity: integrity, disability, and diversity. As we prepare for consultations, we try to locate different family members in terms of these lenses and begin to consider how these lenses shape expectations surrounding gender identity, gender role, and so on. We try to be mindful of how current cultural trends are understood by different stakeholders, including family members, their religious communities, and their other networks of social support and influence.
We are also client-centered. We try to listen to our clients as they sort out their experiences of gender, both past and present; as they negotiate their beliefs about sex and gender; and as they determine how to move forward in their unique family and cultural context, taking into account their religious faith identity and how their faith informs their decision making.
We do not enter into therapy or into a consultation with a fixed outcome in mind. Our concern is not to push a priori conclusions about the best outcome of a client’s gender-identity exploration, in keeping with the approach of others in our field (e.g., Sloan & Berke, 2018; Substance Abuse and Mental Health Services Administration [SAMHSA], 2015). We want to be open-ended, providing services without trying to force the experiences of our clients and families into a single mold. What our clients determine is best for them may range considerably from client to client as we consider a wide range of concerns.
One of the most important considerations we have found in assessment and subsequent care of a child is that parents focus on their unconditional love for their child as a starting point for their interactions around gender identity. When parents enter into the assessment process with assumptions about a normative or particular fixed outcome for their child, our experience has been that these assumptions can be experienced by their child as conditional acceptance. This is a tension we try to address early on. We do not know how a specific child will express their gender identity, how that expression will either stabilize or fluctuate over time, and what a child’s gender identity will ultimately be; however, we do know that a child is best served by parents who express unconditional love and regard for their child.
We tend to rely heavily on parents in the assessment of children. However, it is important to make clinical observations of the child in addition to gathering parental reports. The goal of these observations is to gain a sense of how an outsider might perceive the child based on general impressions. You might think through such areas of gender presentation as clothing, hairstyle, and accessories (e.g., makeup, jewelry, purse, etc.), as well as voice inflection, gestures, and mannerisms. You can also ask yourself, How would someone who did not know this child perceive this child in terms of the child’s gender and why? We typically also note the affect expressed by the child and any concerns they have about the consultation or counseling.
To supplement clinical observation of a child, we have found it helpful to obtain information from parents about what they see at home. This information can be collected over two to three weeks and involves a simple observational record of what parents see. We provide parents with a structure for identifying the kinds of behaviors and experiences that can help us determine whether a diagnosis of Gender Dysphoria is warranted (see worksheet 2.1). For example, we ask parents to make note of their child’s gender-atypical play and activities, gender-related statements about themselves or themselves in comparison to others, preferences for clothing, and so on.
In one case, when preparing for a consultation with parents of a five-year-old child, we asked the parents to complete a daily parent observation form for a two-week period in advance of the consultation. The parents observed the child frequently pulling up his shirt in order to show his belly; selecting morning cartoons and stating, “I only want to watch girl shows”; asking to wear his mother’s sweater; and going into his mother’s closet and coming out with her heels on.
We also invite parents to share how they respond to gender-atypical behaviors in the moment so that we get a better sense for their concerns and their instincts as parents. These exchanges are significant to the counseling process because they can either contribute to a child’s shame or convey a message of love. We have found that when parents experience significant anxiety in this area, they sometimes turn to fear-based parenting techniques they may later regret. A parent might respond to a boy wearing his mother’s high-heeled shoes by sharply scolding him out of anger, for instance; it would be helpful for us to know about this pattern so that we can offer alternative responses.
Parents will often offer differing—and perhaps contradictory—records of what is occurring at home. For this reason, it may be helpful to have parents keep separate records. Clinicians should also get a sense for each parent’s level of daily involvement with the child since factors such as a desire to please a same-sex parent or to hide gender-atypical play may influence parents’ observations.
It may be helpful, too, to obtain information from a teacher about a child’s behavior at school. This avenue of assessment must be weighed against whether the child’s gender-identity exploration is something the family wishes for the school to be made aware of. Parents differ in their degree of comfort involving the school system at this stage of assessment—and as you can imagine, parents also disagree with one another about this from time to time. Some parents express concern that initiating this discussion with school personnel could be stigmatizing for their child, heighten the child’s anxiety in social settings, or prematurely reveal something the child is still working to make sense of. In any case, if parents elect to ask a teacher to complete an observational form, this form covers similar kinds of experiences and observations: the child’s gender-atypical play and activities, gender-related statements about themselves or themselves in comparison to others, preferences for clothing, and so on (see worksheet 2.2).
Interviews.
