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- Herausgeber: IVP Academic
- Kategorie: Religion und Spiritualität
- Serie: Christian Association for Psychological Studies Books
- Sprache: Englisch
Foreword Reviews' INDIEFAB Honorable Mention Genuine Compassion, Expert Understanding—Explore the New Edition of Understanding Gender Dysphoria Few topics spark more debate today than gender identity, fueling intense discussions across social, political, and cultural spheres. Complex issues like gender dysphoria are often oversimplified into slogans and sound bites, overlooking the lived experiences of those affected and making understanding even more difficult in an increasingly divided discourse. Mark Yarhouse, an expert in sexual identity and therapy, challenges the church to rise above the political hostilities and listen to people's stories. In Understanding Gender Dysphoria, Yarhouse combines Biblical principles and scholarly research to offer a Christian perspective on transgender issues that eschews simplistic answers and appreciates both psychological and theological complexity. The result is a book that engages the latest research while remaining pastorally sensitive to the experiences of each person. In this updated edition, you'll find - updated sources and references, - language that reflects the most recent Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR), and - new content on more recent trends, including rising numbers of young people identifying as transgender and non-binary. If you are a pastor, counselor, or someone simply seeking to better understand individuals navigating questions of gender identity, now is the time to act with compassion and courage. Understanding Gender Dysphoria is an essential guide for those who wish to approach this topic with empathy and informed insight. Order your copy today and answer the call to come alongside those on the margins as they resolve their questions and concerns about gender identity. About the Series 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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TO THE CHURCH, THE BODY OF CHRIST:
For wisdom in walking with those who are navigating
gender identity concerns and questions of faith. That we
may all experience the love of the Father, the peace of
Christ, and the presence of the Holy Spirit.
CONTENTS
INTRODUCTION
Most of my professional work has been in the area of sexual identity or the act of labeling oneself based on one’s sexual attractions. In that area of scholarship, I try to be clear about what we know and do not know about sexual identity, while identifying ways in which current research can inform our understanding of how Christians in particular navigate sexual identity questions in their own lives.
Several years ago I was talking with a colleague who was aware of the intense level of scrutiny I receive for my work, often receiving criticism from people or organizations on both sides of the broader culture wars. I was providing a consultation for a family whose daughter was gender dysphoric. He said, “That’s a good idea; maybe move into a less controversial area of work.” He was serious! It was one of those funny moments because I realized he did not know how controversial the issues are surrounding gender dysphoria and transgenderism. That has been confirmed for me as I have conducted research for this book, and in the subsequent work making revisions for this second edition: no one is satisfied with anyone else’s perspective on the topic of gender identity. There are considerable professional and popular divisions that have made it a virtual minefield for any author who wants to step foot on this terrain.
So I want to tread cautiously.
At the same time, I have spent years now meeting with children, adolescents, and adults who have been navigating gender identity concerns, and I had the opportunity to publish one of the first studies of its kind on a sample of Christians who are transgender. Since the publication of the first edition, I have published additional research on Christians navigating this experience. With the revelation of popular figures identifying as trans (e.g., Caitlyn Jenner’s high-profile transition) and legal challenges in Christian institutions for transgender students, faculty, and staff, this topic is clearly moving toward greater cultural salience. Also, since the first edition of Understanding Gender Dysphoria, we have seen a rise in what are referred to as late-onset cases of gender dysphoria, by which is meant the gender dysphoria was first reported at or after puberty rather than in early childhood. How to respond to these late-onset cases has also led to polarization, with many states proposing or passing legislation to ban or limit access to what is referred to as medically affirmative care for transgender youth, while major mental health organizations have taken the position that access to such services is a top priority. Our society is deeply divided.
In 2015, when the first edition of Understanding Gender Dysphoria was published, there was a need for a resource written from a Christian perspective and also informed by the best research we had to date, as well as seasoned with compassion for those who are navigating gender dysphoria. In 2025, there is an even greater need to update where we are in our understanding of this complex phenomenon.
One of the first times I moved from professional discussions about gender dysphoria to a more personal discussion was a few years ago. I had met an acquaintance who is a male-to-female transgender person, that is, a person who adopted a cross-gender identity, a natal male who experiences herself as a woman. This person is also a Christian and lived not too far away. She accepted my invitation to join my family for dinner one day after church. I had not really thought much about it. My parents invited people over for dinner all the time when I was a kid growing up in Pennsylvania and Maryland. But my parents tended to invite missionaries who were home on furlough. This was going to be different, and I don’t know that I thought it all through. Then, as we spoke about finalizing the invitation, I realized she was bringing her wife. I hadn’t really asked much about relationships throughout our initial exchanges. As they shared with me, they were conservative Christians who had been married and raised a family together. They did not believe in divorce. At the same time, they looked like a lesbian couple. I was then beginning to appreciate how complicated this could get.
This experience, together with other personal and professional experiences, led my research group to a series of trainings and consultations around gender dysphoria and eventually to the decision to conduct the study of the experiences of transgender Christians. In the course of conducting that study, we asked several questions of participants to ensure that they were Christians—questions about what being a Christian meant to them and so on. When I presented the results at the Virginia Psychological Association, I found myself presenting the gospel as I read through the content analysis of how participants responded during that part of the interview. Participants referenced a personal relationship with Jesus, recognizing Jesus as their Savior, and so on. At a talk I gave recently on gender dysphoria, a person in the audience challenged the assumption that the people were really Christians: “But how do you know they were Christians?” he asked. “Wouldn’t they just be saying what they thought you wanted to hear, to be included in the study?” I suppose so. That is always a consideration when conducting research. People can misrepresent themselves. But if we took out of every textbook every study that relied on that kind of self-report, we would have pretty thin resources, at least from the behavioral and social sciences. Back to the presentation: The majority of participants denoted starting a personal relationship with Jesus through being saved by grace through faith, thus claiming a conversion experience that is consistent with truth claims that are central tenets of Christianity. It was rather remarkable, really, and it was humbling to me as a Christian and as a researcher.
This book invites Christians to reflect on several issues related to these findings, a broader research literature I will attempt to explain, and other anecdotal accounts. I would like the reader to gain greater insight into the experiences of people who navigate gender dysphoria, recognizing that there is no one story that can capture the range of experiences that exists today. In the opening chapter, I introduce the reader to the language, categories, and key terms associated with the topic. I also note that as we wade into this particular pool, we are going to quickly be in the deep end, as the topic is complex.
The second chapter helps us think through a biblical perspective on gender dysphoria and transgender issues more broadly. I look at the biblical passages that are frequently cited in these discussions. Here I also introduce the reader to three different frameworks or lenses through which the topic can be seen: the integrity framework, the disability framework, and the diversity framework. In addition, I introduce an integrated framework that draws on the best of each of the other frameworks.
Chapter three looks at the debates about causation. There has been a recent attempt to offer a unifying theory of causation (i.e., the brain-sex theory) that captures our current interest in biological explanatory frameworks. Proponents of the brain-sex theory have been criticized by proponents of other theories, and vice versa. I essentially conclude that we would do well to humbly admit that we do not know at this time what causes gender variance or transgender experiences, which has been the primary focus of research to date.
Chapter four explains the phenomenology and prevalence of gender identity issues. In this second edition, the information is updated to the 2022 Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition-Text Revision (DSM-5-TR) diagnostic criteria for Gender Dysphoria. Although the diagnosis of Gender Dysphoria (previously Gender Identity Disorder) is historically rare, recent research suggests gender dysphoria may be experienced along a continuum and that the various expressions of gender variance that fall under the umbrella of transgender are more common. I discuss the rise in the prevalence of young people identifying as transgender and nonbinary, especially late-onset cases, and ask what is going on that might account for these developments.
Chapter five considers issues related to prevention and treatment, particularly when gender dysphoria rises to the level of a diagnosable condition. There are a considerable number of debates here, particularly whether gender dysphoria resolves naturally, whether it can be prevented from continuing into adolescence or adulthood, and whether it should be prevented. The trend this past decade toward medically affirmative care has also been of concern to many. I update this section and reference the most recent World Professional Association for Transgender Health Standards of Care for transgender persons and also critical findings from the Cass Review commissioned by the National Health Service in the UK. There are fewer debates among mental health professionals about treatment options for adults, although there are several paths adults take when they are navigating gender dysphoria, such as resolving to live according to one’s birth sex, managing dysphoria or expressing one’s preferred gender identity part time, or full-time cross-sex identity (a full-time social or medical transition).
Chapter six brings all of what we have covered into a Christian response to gender dysphoria. The focus in this chapter is at the level of the individual, as I discuss how to respond at the level of the individual in clinical practice and ministry contexts.
The last chapter looks at how the church positions itself in relation to the broader culture with respect to gender dysphoria and transgender issues. This is particularly complicated, as the topic of gender dysphoria is subsumed under the transgender umbrella that has been closely associated with the topic of homosexuality. The church has struggled in the twenty-first century with how to conceptualize some of these concerns, as well as how to be a unified witness in the area of sexual ethics. At the level of the institution, there is a question as to what it means to be missional as a church given the dramatic changes in our culture within the past several decades.
I would like to acknowledge the many reviewers who provided me with feedback on earlier versions of the manuscript. I sought out people I knew who were familiar with the topic of gender dysphoria either personally or professionally. The range of perspectives is noteworthy and included transgender, genderqueer, and transsexual persons, each of whom is a Christian, as well as gay and lesbian Christians, and scholars and pastors who are straight and have never experienced gender dysphoria to my knowledge. Specifically, I would like to mention Trista Carr, Stanton Jones, Judson Poling, Julie Rodgers, Melinda Selmys, Sandra Stewart, William Struthers, Caryn LeMur, Peter Ould, and Amy Williams. With this second edition, I remain indebted to all of the previous reviewers and also to Julia Sadusky, Stephen Stratton, Janet Dean, Olya Zaporozhets, and students from the Sexual & Gender Identity Institute, particularly research and teaching assistants David O’Connor and Anna Brose, for their ongoing engagement with me around these topics. The final version is not one any of the reviewers would necessarily endorse, and I take responsibility for it, as they were generous with their time and their suggestions, many of which (but not all) were incorporated into the final manuscript.
ABBREVIATIONS
DSM-5
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Publishing, 2013
DSM-5-TR
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Text Revision. Washington, DC: American Psychiatric Publishing, 2022
GENDER IDENTITY, GENDER DYSPHORIA, AND APPRECIATING COMPLEXITY
On May 30, 1926, George Jorgensen Sr. and Florence Jorgensen welcomed their son, George William Jorgensen, into the world. Danish Americans who had married only four years earlier, they christened George Jr. in the Danish Lutheran Church a few weeks later.1 George Jr. grew up in New York City and graduated from Christopher Columbus High School in the Bronx. He was considered rather slight and frail and interpersonally shy. George Jr. avoided rough-and-tumble play, sports, and other stereotypically male interests. He would go on to study photography at Mohawk College in Utica, and he did a brief stint in the military. He later received training at a medical and dental assistance school in Manhattan.
Growing up in New York, George Jr. often felt that he had some kind of sexual and emotional disorder. In search of answers, he investigated possible explanations by scouring books and articles at the New York Academy of Medicine library. His fear was that he was homosexual; after all, he was sexually attracted to men. However, that did not appear to explain everything. George Jr. eventually experimented with the female hormone estradiol, and he learned during this time about a possible intervention taking place in Sweden that extended his experiments into a more meaningful and satisfying resolution. He went overseas and eventually found Dr. Christian Hamburger, an endocrinologist who was willing to provide him with hormonal replacement therapy. George Jr. later had his testicles and penis removed; he also had vaginal plastic surgery. In 1952, George Jr. changed his name to Christine Jorgensen out of respect for Dr. Christian Hamburger.
We are talking about the 1950s. This course of events made headlines. The New York Daily News banner headline read in all capital letters: “EX-GI BECOMES BLONDE BEAUTY: OPERATIONS TRANSFORM BRONX YOUTH.” Although Christine was not the first person to undergo gender confirmation surgery, she noted in her autobiography that she was the most well known at that time.
Gender identity concerns were not that well understood in the 1950s. Frankly, they are not that well understood today. There are many questions left unanswered about what causes a person to have the psychological experience of being born in the wrong body.
Controversies also exist in the area of treatment or care: How should parents respond when a child displays behaviors more characteristic of the opposite sex? Should cross-gender identification be redirected toward identification with one’s birth sex? Should transitioning (adopting a cross-gender identification) be encouraged for a child who is already gender dysphoric? Should puberty be delayed to provide time for that kind of decision making? What options exist for teens and adults? Should they be encouraged to enter into therapy to resolve the conflict through psychological intervention? Is cross-gender identification to be avoided, or should it be facilitated? When people have tried different interventions, what has been helpful? What are the reasons people pursue hormonal treatment and gender confirmation surgery? How often are these procedures helpful to people? What are the long-term effects of these kinds of interventions?
These are remarkably complicated questions that deserve our attention. We are no longer answering these questions in the cultural context of the 1950s. One difference we can all acknowledge is that our culture has shifted toward more supportive and varied sexual and gender identity labels and communities that are very accessible to people and their families. As the cover of Time magazine declared in 2014, we have reached the transgender tipping point. There have certainly been increased attempts to understand and respond to this often-bewildering experience.
The changing culture can be seen in both professional and popular treatment of the phenomenon. In the professional literature, the DSM-5 reflected a shift away from Gender Identity Disorder toward the use of the phrase Gender Dysphoria to reduce stigma.2 (This was reaffirmed in the 2022 Text Revision of the DSM-5-TR.) Actually, several steps in the new nomenclature were intended to reduce stigma. The first was the shift from an emphasis on identity as the disorder to an 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.
Our culture has in some 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 transwoman (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 represent the kind of cultural sea change that would soon follow.
The shift in the popular media can also be seen in journalism. Several years ago the late Barbara Walters aired a special in which she interviewed a young biological male who was being raised as a girl.3 In discussing the decision of the parents to raise their son as a daughter, there was tremendous compassion generated around the challenges those parents and that family faced. In that same story, Walters interviewed an adolescent female who identified as male. Walters interviewed his parents, and they shared the challenges they faced, particularly for the mother in terms of wanting this to resolve in a way that would return her daughter to her. These are heartbreaking stories and challenging for everyone involved.
In response to this increased coverage, I asked the questions above: When a child is gender dysphoric, how should parents respond? Should parents raise a gender dysphoric child in the identity of the child’s biological sex? Should they facilitate cross-gender identification? Or should they take a “wait and see” posture, with the assumption that the right direction for that child is what will unfold?
In addition to questions about gender dysphoric children, What are the obligations for employers who have transgender employees? How should bathrooms be designated? Should medical coverage extend to hormonal treatment and gender confirmation surgery? What about room assignments at campgrounds and at colleges and universities? What about hiring policies at churches, faith-based ministries, and Christian colleges and universities?
As churches consider relating to a dramatically changing culture, what steps should be taken to reach unchurched persons who identify as transgender or who are part of the transgender community? Are there specific steps that could be considered to accommodate the experiences of gender dysphoric persons who visit churches?
In all of these discussions it should be noted, too, that the transgender experience is not one experience; it is best understood as an umbrella term for the many ways in which people might experience their gender identities differently from people whose gender identity is congruent with their birth sex. The experiences vary considerably and are only matched by presentation and expression or the living out of one’s gender identity, which can range from pushing against gender norms (gender “bending”), to cross-dressing for show/performance/entertainment (drag), to adopting a cross-gender (trans) or other-gender identity (nonbinary).
The transgender community, then, is broadly defined, and it has positioned itself alongside sexual minorities in the broader cultural discourse. Sexual minorities are people who experience their sexual identity in ways that are different from those in the majority (gay, lesbian, bisexual). When we speak of sexual minorities, then, we are typically referring to how people navigate sexual identity and convey their sexual preferences to themselves privately or to others publicly (e.g., frequently using the self-defining attribution “I am gay”).
To enter into an informed discussion of transgender issues is to switch gears a little away from a discussion about sexual orientation. We can return to it, but it is not the focal point in the way it is when discussing homosexuality, heterosexuality, and bisexuality.
To discuss being transgender is to discuss one’s experience of gender identity, one’s sense of oneself as a man or a woman, a boy or a girl, or a different experience from that, and how that psychological and emotional experience is not aligning with one’s natal sex.
BACKGROUND
To begin to understand gender dysphoria, it can be helpful to back up and discuss a broader context based on our understanding of sex and gender. When we refer to a person’s sex, we are commonly making reference to the physical, biological, and anatomic dimensions of being male or female.4
These facets include chromosomes, gonads, sexual anatomy, and secondary sex characteristics.
KEY TERMS
Biological sex: As male or female (typically with reference to chromosomes, gonads, sex hormones, and internal reproductive anatomy and external genitalia).
Natal sex: The sex that a child is designated at birth, typically based on biological characteristics.
Primary sex characteristics: Features that are directly part of the reproductive system, such as testes, penis, and scrotum in males, and ovaries, uterus, and vagina in females.
Secondary sex characteristics: Have no direct reproductive function, for example, facial hair in males and enlarged breasts in females.
Gender: The psychological, social, and cultural aspects of being male or female.
Gender identity: How one experiences or identifies oneself as a man or a woman, a boy or a girl, or a different experience of gender from that.
Gender role: Adoptions of cultural expectations for maleness or femaleness.
Sex is frequently distinguished from gender. Gender refers to the psychological, social, and cultural aspects of being male or female. When we refer to someone’s gender identity, we are thinking of how a person experiences him- or herself as a man or woman, a boy or girl, or a different experience of gender from that. Gender identity is often associated with gender role. Gender role, then, refers to ways in which people adopt cultural expectations for maleness or femaleness. This includes but is not limited to academic interests, career pursuits, and so on.
For most people, these various facets or dimensions of sex and gender align in ways that are essentially taken-for-granted realities. Most people you have met have a relatively unremarkable experience (or remarkable in the sense of all of these facets coming into alignment) of being born male or female (with the alignment of the various biological/physical/anatomical features noted above), identifying as a man or a woman, and feeling masculine or feminine within the cultural context in which they are raised.
But variations occur in these areas. For example, there is likely greater variability in how masculine or feminine a person feels, and that is often a reflection of whether they are reared in an environment with rigid gender roles and how well that person’s experiences line up with those expectations.
These variations occur in other areas as well and are often discussed as differences of sex development (also referred to as intersex or an intersex condition).5 In the area of biological/physical/anatomical sex, we can note several deviations from the norm of being born male or female. For example, a former client of mine had been diagnosed with Klinefelter syndrome, a genetic disorder of gonadal differentiation in which that person had an extra X chromosome (XXY).6 Another person could be born with either incomplete or mixed ovarian and testicular tissues, a condition that has often been referred to previously as true hermaphroditism.7
Table 1.1. Physical/biological/anatomical facets of being male or female
FACET
MALE
FEMALE
Chromosomes
XY
XX
Gonads
Testes
Ovaries
Sexual anatomy
Scrotum, penis, vas deferens, etc.
Labia, clitoris, vagina, fallopian tubes, etc.
Secondary sex characteristics
Greater muscle mass, etc.
Wider hips, enlarged breasts, etc.
A friend of mine has yet another physiological condition—androgen insensitivity syndrome—as a result of malfunctioning gonads and other prenatal concerns. Although she does not choose to identify as intersex, many of these individuals would describe themselves that way, referring to any number of variations from the norm that make identifying as male or female problematic.
Table 1.2. Understanding sex and gender
Biological sex
Male
Female
Gender identity
Man
Woman
Gender role
Masculine
Feminine
Where do gender identity concerns fit into all of this? I locate androgyny in between man and woman as gender identity. Androgyny can refer to not having a clearly defined sense of self as a man/woman, or it can refer to a bringing together of male/female qualities or characteristics.
Table 1.3. Exceptions to binaries
Biological sex
Male
Intersex
Female
Gender identity
Man
Androgyny
Woman
Gender role
Masculine
Outside cultural norms
Feminine
This book is about an experience that is different from what I have been discussing so far, although there are elements of biological sex, gender role, and gender identity that are all important in the discussion. Gender identity concerns—or what we refer to as gender dysphoria—refers to experiences of gender identity in which one’s psychological and emotional experience of oneself as female, for instance, does not match or align with one’s natal sex as male. This has historically been the more common presentation, but the reverse may also be experienced and is much more common today among adolescents and emerging adults: one’s psychological and emotional experience of oneself as male does not match or align with one’s natal sex as female.
Our illustration changes, then, to something that does challenge the binary, but it does so not by residing in between the two experiences of man/woman; rather, the experience locates itself in the other (psychologically/emotionally) in ways that are often quite difficult to fully understand or empathize with.
Figure 1.1.
The graphic says Gender Identity on the left. On the right, it says Man, Gender Dysphoria, and Woman, with arrows pointing from Man to Woman and from Woman to Man.
If euphoria is a positive emotional state, dysphoria is a negative emotional state in which something is significantly distressing. Thus, gender dysphoria refers to the experience of distress that can be associated with gender discordance in which a one’s psychological and emotional identity does not correspond to one’s biological sex, which is thought of with reference to chromosomes, gonads, and genitalia. This experience of incongruity or discordance can be the source of deep and ongoing discomfort. When a person experiences gender discordance and it is causing them significant distress or impairment, they may meet criteria for the diagnosis of Gender Dysphoria.8
KEY TERMS
Gender dysphoria: The experience of 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 and express (or live out) their gender identities differently from people whose sense of gender identity is congruent with their biological sex.
Cisgender: A word to contrast with transgender and to signify that one’s psychological and emotional experience of gender identity is congruent with one’s biological sex.9
Gender bending: Intentionally crossing or “bending” gender roles.
Cross-dressing: Dressing in the clothing or adopting the presentation of the other sex. Motivations for cross-dressing vary significantly.
Third sex or third gender: A term used to describe persons who are neither man nor woman, which could reference an intermediate state or another sex or gender, or having qualities of both man/woman in oneself.
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 gender confirmation surgery. (Many in the transgender community prefer the term transgender to transsexual, as the latter can be experienced as too psychiatric or pathologizing.)
Male-to-Female (MtF) or transwoman: A person who is identified as male at birth but experiences a female gender identity and has or is in the process of adopting a female presentation.
Female-to-Male (FtM) or transman: A person who is identified as female at birth but experiences a male gender identity and has or is in the process of adopting a male presentation.
Gender nonbinary: An umbrella term for emerging gender identities that reside in between the binary of man/woman or outside that binary (e.g., pangender, greygender, masculine-of-center, feminine-presenting, demiboy, demigirl).
Genderfluid: A term used when a person wants to convey that their experience of gender is not fixed as either male/female but may either fluctuate along a continuum or encompass qualities of both gender identities.
Drag queen: A biological male who dresses as a female (typically flamboyant dress and appearance) for the purposes of entertaining others. Such a person may not experience gender dysphoria and does not tend to identify as transgender.
Drag king: A biological female who dresses as a male (stereotypic dress and appearance) for the purposes of entertaining others. As with drag queens, such a person may not experience gender dysphoria and does not tend to identify as transgender.
Transvestism: Dressing or adopting the presentation of the other sex, typically for the purpose of sexual arousal (may reflect a fetish quality). Such a person may not experience gender dysphoria and may not identify as transgender. Most transgender persons do not cross-dress for arousal and see transvestism as a different phenomenon from what they experience.
Differences of sex development (intersex): These describe conditions (e.g., congenital adrenal hyperplasia) in which a person is born with sex characteristics or anatomy that does not allow clear identification as male or female. The causes of differences of sex development can be chromosomal, gonadal, or genital.
However, as we broaden the discussion to transgender issues, we begin to extend the discussion beyond merely the experience of gender dysphoria, an experience that might be characterized by gender incongruence in which the person does not experience an aligning of natal sex and psychological sense of gender. Transgender is an umbrella term for the many ways in which people might experience and/or present and express (or live out) their gender identities differently from people whose sense of gender identity is congruent with their biological sex.
A person could be under the transgender umbrella and be gender dysphoric (experiencing significant incongruence that is distressing). Another person could cross-dress and find the act of cross-dressing sexually arousing (but they might not experience the gender dysphoria the other person reports). Still another person could cross-dress with a strong desire to start hormonal treatment with an eye for gender confirmation surgery. Yet another person could do drag shows and be quite flamboyant in presentation (e.g., drag queen or drag king), which may have little if anything to do with a subjective experience of dysphoria or a desire for sexual arousal. That person would be unlikely to identify as transgender, although some might, and that person’s decision could be tied to motivations to cross-dress in this manner.
It should be noted that not every expression of gender variance defined in the sidebar would report gender dysphoria. Most people who have an intersex condition, for instance, do not experience gender dysphoria, although they have a higher incidence rate than those who do not have an intersex condition, and many would report going through a time of navigating gender identity questions.10 Likewise, most people who perform in drag would not report gender dysphoria as such and may not identify themselves as transgender—nor would those who do identify as transgender necessarily consider those who perform drag to be transgender.
If you are beginning to get the sense that this could get complicated, you are not alone. 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 the church is going to need to spend some time on this topic. I urge church leaders to spend time in careful reflection as we think about the best way to engage the broader culture from more of a missional approach while simultaneously considering how to come alongside people within our own Christian communities who are navigating this terrain.
TOWARD A REASONED RESPONSE
This brings us back to the person. I am thinking here of the person who is navigating gender identity questions in his or her life. I am thinking of the person who experiences gender dysphoria. That experience of gender incongruence—the experience of biological sex and psychological experience of gender not aligning—can also be experienced along a continuum. In other words, gender identity concerns are not one thing experienced in exactly the same way by all people everywhere who experience it. Rather, think about the experience of incongruence and distress/discomfort reflecting different degrees of both incongruence and discomfort.
What is the best way to proceed for the person who experiences gender dysphoria? The remainder of this book takes that into consideration, but let me outline a few things for us to consider as we move in the direction of a more thoughtful response.
Let’s consider what we have said so far: the person is navigating gender identity concerns. These concerns are real and often quite confusing and isolating. The person worries about who would believe them, what people would think about them, and so forth. This is tremendously isolating and often associated with other concerns, such as depression and anxiety. One reviewer shared with me that she had a good friend who cross-dressed and abused a significant amount of alcohol to suppress her dysphoria; she shared that the substance abuse abated once her friend was able to come to a place of congruence.
Gender dysphoria has historically not been a particularly common concern. That has changed in the last decade or so. Still, most people experience a remarkable alignment of the many facets that make up biological sex and their sense of themselves as male or female. But for those who experience gender identity conflicts, the church will need to consider how best to respond.
At the level of the individual, it can be helpful to ask a simple question, such as: How do you experience gender discordance? Invite the person to tell you more about their experiences.
Figure 1.2.
A speech bubble from the male stick figure says, "How is the gender identity conflict experienced by this person? "
Keep in mind, too, that the person is navigating gender identity questions in a cultural context in which many people will respond to them out of a culture-war mentality. Cultural polarization has only increased in intensity in the last decade. No one navigates gender identity concerns in a vacuum. Rather, each person who faces this unique challenge does so in a sociocultural context in which sex and gender are being discussed and debated.
Figure 1.3.
A speech bubble from the top left corner of the illustration says, "These concerns are being navigated in a specific cultural context. "
As I mentioned earlier, some people are capitalizing on discussions in this area to deconstruct sex and gender. I will discuss this in greater detail in chapter two. David Kinnaman of the Barna Group, in discussing gay marriage and reflecting on our rapidly changing culture, observed in 2013,
The data shows that evangelicals remain countercultural against a rising tide of public opinion. If the sands have shifted under evangelicals’ feet in the last 10 years, we at Barna predict it will seem the ground has completely opened beneath them during the next 10. In part, that’s because the very belief that same-sex relationships are morally wrong is deemed by many to be discriminatory and bigoted.11
This comment by Kinnaman is in reference to same-sex sexuality, but the overarching discussion is about LGBTQ+ issues in general. We are at the point that Kinnaman predicted evangelicals would experience the sand as opening up beneath them. If you are feeling that way, you are not alone. The cultural opinion surrounding gay marriage represents a broader cultural opinion that extends to transgender issues and gender diverse persons. These cultural shifts frequently trigger responses from social conservatives of concern and, in some cases, fear for the erosion of long-held norms. These battles are played out in politics, entertainment, the media, and education. The person you are talking to is unlikely involved in these spheres but may simply be looking for support as they navigate this terrain.
As Christians provide care to people in a sociocultural context characterized by ideological and political battles, we need to think about rising above the culture war when providing ministry and meaningful pastoral care and support. We keep it in view (it is inescapable) while we provide services and compassionate care.
Why is this important? There is good reason to believe that the next generation of Christians tends to value a relational ethic that does not sacrifice relationships even when drawing distinctions in ethics and morality: “The Christian response to these issues [marriage, ethics, human flourishing, and so on] has to be rooted in a deeply relational ethic—that sexuality is a relational and interconnected aspect of our humanity. That relationships matter, including those between people who disagree.”12 We will want to keep this in mind, and this book is intended to respect that shift in how discussions are carried out between people where there is disagreement, but it is at least important to recognize this cultural shift among Christians.
Unfortunately, one way people respond to transgender issues is to devalue the person who is gender discordant or experiences gender dysphoria and simultaneously turn to rigid stereotypes of gender. Not only is that reaction overly restrictive, but it can create a forced choice for those who do not fit into those rigid categories. It won’t be helpful to stress stereotypes that people are unable to adopt. Also, keep in mind that we have witnessed a cultural shift that may contribute to greater uncertainty around sex and gender.13
I will share later some thoughts and suggestions on what it looks like to live out various expressions of gender identity concerns, but generally speaking, I can see the value in encouraging individuals who experience gender identity conflicts to resolve the conflicts in keeping with their birth sex if possible. Where those strategies have been unsuccessful, I recognize the potential value in managing the gender identity conflict or concern through the least invasive means (recognizing surgery as the most invasive step toward expression of one’s internal sense of identity). I will come back to this, as it warrants more attention. There is a risk, too, with so much media attention focusing almost exclusively on transsexuality while there are many other expressions and experiences of transgenderism and gender variance. I will say this for now: Given the complexities associated with these issues and the potential for many and varied presentations, pastoral sensitivity should be a priority.
I know many people who are navigating gender identity concerns who love Jesus and are desperately seeking to honor him. I think it would be a mistake to see these individuals as rebellious (as a group) or as projects. Some do identify as transgender or use other labels or ways of naming their reality, and I would like the church to provide a supportive environment for them as they navigate this difficult terrain.
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 the least invasive ways to manage the gender identity concerns. I will return to this principle throughout the book, but the idea is that there are many ways in which a person who experiences gender identity concerns along a continuum might manage experiences of gender dysphoria. Just as the experiences reside along a continuum, so too do the possibilities for exploration of identity and management of what contributes to gender dysphoria.
CONCLUDING THOUGHTS
Gender identity concerns (including gender discordance and gender dysphoria) remain some of the most complex and difficult experiences to fully understand. We know so little about the etiology and best course of care, though there are strong proponents for different theories and approaches, and there is division among mental health professionals on some important points as well as between some mental health professionals and some members of the transgender community. We will discuss each of these issues in greater detail in subsequent chapters.
On the topic of treating gender dysphoric children, there was a time when professionals focused on resolving gender dysphoria to reach congruence with the child’s natal sex. Today this is viewed with great skepticism; vocal critics from not only the transgender community but mainstream mental health associations have expressed how this is not unlike conversion therapy for gay people. Also, once a child reaches late adolescence or adulthood, there are few large-scale studies of psychosocial interventions toward this end, and even less optimism for such a resolution once a person has reached adulthood. Perhaps as a result, the field has moved in the direction of support for those who wish to pursue cross-gender or other gender identification, with several models to support such cross-gender or other gender identification through puberty suppression. Once a person has waited a year or two, consideration is then given to medical interventions to facilitate cross-gender identification, and these may include hormonal treatment and gender confirmation surgery.
As we close this chapter, I want to point out a study we conducted of transwomen (male-to-female transgender) Christians.14 In it we noted conflicts with gender identity and religious identity in terms of personal faith, God, and the local church.15 Interestingly, 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. Particularly common was past conflict with the local church community or the persons and leaders who represented these organizations. I will return to this study and others throughout this book, as some of the information shared in that context may inform our broader discussion.
It is unclear to me at this time whether there is any one outcome that is ultimately satisfying to everyone who has a stake in these discussions. It has historically been such a rare condition that we have had little good research from which to draw strong conclusions, and I have known people who felt gender dysphoria so strongly that they felt nothing less than their sanity and their life was at stake. They desperately sought a resolution to the dysphoria that caused them significant distress and impairment. This is not an argument that they should pursue the most invasive procedures, but we also acknowledge that we understand and empathize with that decision, as painful as it often is. In recent years, we have seen a rise in late-onset cases of gender dysphoria, cases in which the gender dysphoria is experienced for the first time at or after puberty. The increase in late-onset cases has been noted particularly among natal females. Research on atypical cases remains rather sparse, particularly long-term-outcome studies of adolescents navigating medical interventions that may be available to them in some jurisdictions.
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 the least invasive ways to manage the dysphoria. Perhaps future programs of research will provide greater insight and clarity into an area that seems particularly difficult to navigate at this time. These include but are not limited to research on the types of resolutions sought by people with an eye for the developmental considerations associated with gender dysphoria in childhood, adolescence, and adulthood; how strength of gender dysphoria is related to various attempted resolutions; the role of personal values and religious faith commitments in seeking resolutions; and so on. 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.
