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M A R K A . YA R H O U S E

U N D E R S TA N D I N G

G E N D E RD Y S P H O R I A

I S S U E S I N A C H A N G I N G C U LT U R E

N AV I G AT I N G T R A N S G E N D E R



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U N D E R S TA N D I N G

G E N D E RD Y S P H O R I A

N AV I G AT I N G T R A N S G E N D E R

I S S U E S I N A C H A N G I N G C U LT U R E

MARK A. YARHOUSE

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Library of Congress Cataloging-in-Publication DataYarhouse, Mark A., -Unders anding gender dysphoria : naviga ing ransgender issues in a

changing cul ure / Mark A. Yarhouse. pages cm

Includes bibliographical re erences and index. ISBN - - - - (pbk. : alk. paper)

. Sex--Religious aspec s--Chris iani y. . Gender iden i ydisorders. . Gender iden i y--Religious aspec s--Chris iani y. I.Ti le.

BT .Y . ’ --dc

P

Y




Contents

In roduc ion

Gender Iden i y, Gender Dysphoria and Apprecia ing Complexi y

A Chris ian Perspec ive on Gender Dysphoria

Wha Causes Gender Dysphoria?

Phenomenology and Prevalence

Preven ion and rea men o Gender Dysphoria oward a Chris ian esponse: A he Level o he Individual

oward a Chris ian esponse: A he Level o he Ins i u ion

No es

Index




Introduction

M has been in he area o sexualiden i y or he ac o labeling onesel based on one’s sexual atrac ions. In area o scholarship, I ry o be clear abou wha we know and do no knabou sexual iden i y, while iden i ying ways in which curren research cin orm our unders anding o how Chris ians in par icular naviga e sexuiden i y ques ions in heir own lives.

Several years ago I was alking wi h a colleague who was aware o he in elevel o scru iny I receive or my work, ofen receiving cri icism rom peopleorganiza ions on bo h sides o he broader cul ure wars. I was providing a cosul a ion or a amily whose daugh er was gender dysphoric. He said, “Ta ’good idea; maybe move in o a less con roversial area o work.” He was seriouI was one o hose unny momen s because I realized he did no know hocon roversial he issues are surrounding gender dysphoria and ransgenderism

Ta has been conrmed or me as I have conduc ed research or his bookno one is sa ised wi h anyone else’s perspec ive on he opic o gender idenTere are considerable pro essional and popular divisions ha have made i a vir ual mineeld or any au hor who wan s o s ep oo on his errain.

So I wan o read cau iously. A he same ime, I have spen years now mee ing wi h children, ado

cen s and adul s who have been naviga ing gender iden i y concerns, andhave had he oppor uni y o publish one o he rs s udies o i s kind

sample o Chris ians who are ransgender. Wi h he revela ion o popugures iden i ying as rans (e.g., Cher’s child who is a biological emale annamed Chas i y Bono a bir h and now iden ies as male, Chaz Bonoand legal challenges in Chris ian ins i u ions or ransgender s uden s, a




UNDE S AN DING GENDE DYSPHO I A

and s aff, his opic is clearly moving oward grea er cul ural salience.Te ac is ha here is a need or a resource ha is writen rom a Chris ian

perspec ive and is also in ormed by he bes research we have o da e, as wellas seasoned wi h compassion or he person who is naviga ing gender dys-phoria. I hough i would be wor h rying o pu oge her ha kind o re-source, and he reader will be lef o decide whe her I have succeeded, as he whole opic is difficul o ully unders and le alone explain.

One o he rs imes I moved rom pro essional discussions abou genderdysphoria o a more personal discussion was a ew years ago. I had me an ac-quain ance who is a male- o- emale ranssexual person and a Chris ian and who lived no oo ar away. She accep ed my invi a ion o join my amily ordinner one day afer church. I had no really hough much abou i . My paren sinvi ed people over or dinner all he ime when I was a kid growing up inPennsylvania and Maryland. Bu my paren s ended o invi e missionaries who were home on urlough. Tis was going o be differen , and I don’ know ha I

hough i all hrough. Ten, as we spoke abou nalizing he invi a ion, I re-alized she was bringing her wi e. I hadn’ really asked much abou rela ionships

hroughou our ini ial exchanges. As hey shared wi h me, hey were conserva ive Chris ians who had been married and raised a amily oge her. Tey didno believe in divorce. A he same ime, hey looked like a lesbian couple. I was

hen beginning o apprecia e how complica ed his could ge .Tis experience, oge her wi h o her personal and pro essional experiences,

led my research group o a series o rainings and consul a ions around genderdysphoria and even ually he decision o conduc he s udy o he experiences

o ransgender Chris ians. In he course o conduc ing ha s udy, we askedseveral ques ions o par icipan s o ensure ha hey were Chris ians ques-ions abou wha being a Chris ian mean o hem and so on. When I pre-

sen ed he resul s a he Virginia Psychological Associa ion, I ound myselpresen ing he gospel as I read hrough he con en analysis o how par ici-pan s responded during ha par o he in erview. Par icipan s re erenced apersonal rela ionship wi h Jesus, recognizing Jesus as heir Savior, and so on.

A a alk I gave recen ly on gender dysphoria, a person in he audience chal-lenged he assump ion ha he people werereally Chris ians: “Bu how do youknow hey were Chris ians?” he asked. “Wouldn’ hey jus be saying wha

hey hough you wan ed o hear, o be included in he s udy?” I suppose so.Ta is always a considera ion when conduc ing research. People can misrep-




In roduc ion

resen hemselves. Bu i we ook ou o every ex book every s udy haon ha kind o sel -repor , we would have prety hin resources, a leas

he behavioral and social sciences. Back o he presen a ion: Te majori y par icipan s deno ed s ar ing a personal rela ionship wi h Jesus hrough bsaved by grace hrough ai h, hus claiming a conversion experience haconsis en wi h ru h claims ha are cen ral ene s o Chris iani y. I wremarkable, really, and i was humbling o me as a Chris ian and as a research

Tis book invi es Chris ians o reec on several issues rela ed o hendings, a broader research li era ure I will atemp o explain, and o her aecdo al accoun s. I would like he reader o gain grea er insigh in o he riences o people who naviga e gender dysphoria, recognizing ha here is none s ory ha can cap ure he range o experiences ha exis s oday. Iopening chap er, I in roduce he reader o he language, ca egories and k

erms associa ed wi h he opic. I also no e ha as we wade in o his parpool, we are going o quickly be in he deep end, as he opic is complex.

Te second chap er helps us hink hrough a biblical perspec ive on genderdysphoria and ransgender issues more broadly. I look a he biblical passage

ha are requen ly ci ed in hese discussions. I is here ha I also in rohe reader o hree differen rameworks or lenses hrough which he opic

be seen: he in egri y ramework, he disabili y ramework and he diveramework. In addi ion, I in roduce an in egra ed ramework ha drawshe bes o each o he o her rameworks.Chap er hree looks a he deba es abou causa ion. Tere has been a recen

atemp o offer a uni ying heory o causa ion (i.e., he brain-sex heory)

cap ures our curren in eres in biological explana ory rameworks. Proponeo he brain-sex heory have been cri icized by proponen s o o her heories vice versa. I essen ially conclude ha we would do well o humbly admi hado no know a his ime wha causes gender variance or ransgender experienincluding ranssexuali y, which has been he primary ocus o research o da

Chap er our explains he phenomenology and prevalence o genderiden i y issues. I review he curren Diagnos ic and S a is ical Manual o Men Disorders, Fifh Edi ion ( DSM-) diagnos ic cri eria or Gender Dysphoria. Al-

hough he diagnosis o Gender Dysphoria (previously Gender Iden i y Diorder) is rare, recen research sugges s gender dysphoria may be experiencedalong a con inuum and ha he various expressions o gender variance h

all under he umbrella o ransgender are more common.





Chap er ve considers issues rela ed o preven ion and rea men , par icu-larly when gender dysphoria rises o he level o a diagnosable condi ion.

Tere are a considerable number o deba es here, par icularly whe her genderdysphoria resolves na urally, whe her i can be preven ed rom con inuing in oadolescence or adul hood, and whe her i should be preven ed. Tere are

ewer deba es among men al heal h pro essionals abou rea men op ions oradul s, al hough here are several pa hs adul s ake when hey are naviga inggender dysphoria, such as resolving o live according o one’s bir h sex, man-aging dysphoria or expressing one’s pre erred gender iden i y in ermiten ly,or ull- ime cross-sex yped iden ica ion.

Chap er six brings all o wha we have covered in o a Chris ian response ogender dysphoria. Te ocus in his chap er is a he level o he individual, asI discuss how o respond a he level o he individual in clinical prac ice andminis ry con ex s.

Te las chap er looks a how he church posi ions i sel in rela ion o he broader cul ure wi h respec o gender dysphoria and ransgender issues. Tisis par icularly complica ed, as he opic o gender dysphoria is subsumed

under he ransgender umbrella ha has been closely associa ed wi h he opico homosexuali y. Te church has s ruggled in he wen y-rs cen ury wi hhow o concep ualize some o hese concerns, as well as how o be a unied wi ness in he area o sexual e hics. A he level o he ins i u ion, here is aques ion as o wha i means o be missional as a church given he drama icchanges in our cul ure wi hin he pas several decades.

I would like o acknowledge he many reviewers who provided me wi h

eedback on earlier versions o he manuscrip . I sough ou people I knew who were amiliar wi h he opic o gender dysphoria ei her personally or pro es-sionally. Te range o perspec ives is no ewor hy and included ransgender, gen-derqueer, and ranssexual persons, each o whom is a Chris ian, as well as gay andlesbian Chris ians, and scholars and pas ors who are s raigh and have never ex-perienced gender dysphoria o my knowledge. Specically, I would like omen ion ris a Carr, S an on Jones, Judson Poling, Julie odgers, MelindaSelmys, Sandra S ewar , William S ru hers, Caryn LeMur, Pe er Ould and Amy Williams. Te nal version is no one any o he reviewers would necessarily en-dorse, and I ake responsibili y or i as hey were generous wi h heir ime and

heir sugges ions, many o which (bu no all) were incorpora ed in o he nalmanuscrip .




1

Gender Identity, Gender Dysphoriaand Appreciating Complexity

INTRODUCTIONOn May , , George Jorgensen Sr. and Florence Jorgensen welcomed

heir son, George William Jorgensen, in o he world. Danish Americans whohad married only our years earlier, hey would chris en George Jr. in hDanish Lu heran Church a ew weeks la er.1 George Jr. grew up in New YorkCi y and gradua ed rom Chris opher Columbus High School in he BronxHe was considered ra her sligh and rail and in erpersonally shy. George Javoided rough-and- umble play, spor s and o her s ereo ypically male i

eres s. He would go on o s udy pho ography a Mohawk College in Uand did a brie s in in he mili ary. He la er received raining a a medicalden al assis ance school in Manhatan.

Growing up in New York, George Jr. ofen el ha he had some kind o

sexual and emo ional disorder. In search o answers, he would inves iga e posible explana ions by scouring books and ar icles a he New York Academo Medicine library. His ear was he was homosexual; afer all, he was sexuallatrac ed o men. However, ha did no appear o explain every hing. Geor Jr. even ually experimen ed wi h he emale hormone es radiol, and he learnduring his ime abou a possible in erven ion aking place in Sweden ex ended his experimen s in o a more meaning ul and sa is ying resoluHe wen overseas and even ually ound Dr. Chris ian Hamburger, an endocrinologis who was willing o provide him wi h hormonal replacemen heraGeorge Jr. would la er have his es icles and penis removed; he also had vaginplas ic surgery. In , George Jr. changed his name oChris ine Jorgensen ouo respec or Dr.Chris ian Hamburger.





We are alking abou he s. Tis course o even s would make headlines.Indeed, he New York Daily News banner headline read in all capi al leters:

“EX-GI BECOMES BLONDE BEAU Y: OPER IONS RNFO MB ONX YOU H.” Al hough Chris ine was no he rs person o undergosex-reassignmen surgery, she no ed in her au obiography ha she was hemos well known a ha ime.

Gender iden i y concerns were no ha well unders ood in he s.Frankly, hey are no ha well unders ood oday. Tere are many ques ions lefunanswered abou wha causes a person o have he psychological experienceo being born in he wrong body.

Con roversies also exis in he area o rea men or care: How shouldparen s respond when a child displays behaviors more charac eris ic o heopposi e sex? Should cross-gender iden ica ion be redirec ed oward iden-

ica ion wi h one’s bir h sex? Should cross-gender iden ica ion be en-couraged or a child who is already gender dysphoric? Should puber y bedelayed o provide ime or ha kind o decision making? Or wha op ionsexis or eens and adul s? Should hey be encouraged o en er in o herapy

o resolve he conic hrough psychological in erven ion? Is cross-genderiden ica ion o be avoided, or should i be acili a ed? When people have

ried differen in erven ions, wha has been help ul? Wha are he reasonspeople pursue hormonal rea men and sex-reassignmen surgery? Howofen are hese procedures help ul o people? Wha are he long- erm effec so hese kinds o in erven ions?

Tese are remarkable complica ed ques ions ha deserve our aten ion.

We are no longer answering hese ques ions in a cul ural con ex o hes. One difference we can all acknowledge is ha our cul ure has shifedoward more suppor ive and varied sexual and gender iden i y labels and com-

muni ies ha are very accessible o people and heir amilies. Tere have cer-ainly been increased atemp s o unders and and respond o his ofen bewil-

dering experience.Te changing cul ure can be seen in bo h pro essional and popular

rea men o he phenomenon. In he pro essional li era ure, he Diagnos icand S a is ical Manual o Men al Disorders, Fifh Edi ion( DSM-)2 reec ed ashif away rom Gender Iden i y Disorder oward he use o he phraseGender Dysphoria3 o reduce s igma. Ac ually, several s eps in he new no-mencla ure were in ended o reduce s igma. Te rs is he shif rom an





emphasis on iden i y as he disorder o he emphasis on he dysphoria dis ress associa ed wi h he gender incongruence or many people wh

repor i . Te o her was he wording o allow or someone o no longer mecri eria ollowing a ransi ion.

Our cul ure has in some ways moved pas he afernoon elevision showsha capi alized on “shock and awe” in heir presen a ions, where you mi

see producers orches ra e a drama ic con ron a ion be ween a male- o- emransgender person who once da ed a woman and is now surprising her wi h

her rue sense o sel . Tese color ul presen a ions in he media were once expression o almos gawking a he phenomenon, bu hey did no repres

he kind o cul ural sea change ha would soon ollow.Te shif in he popular media can also be seen in journalism. A ew years

ago Barbara Wal ers aired a special in which she in erviewed a young biological male who was being raised as a girl.4 In discussing he decision o heparen s o raise heir son as a daugh er, here was remendous compassiogenera ed around he challenges hose paren s and ha amily aced. In same s ory, Wal ers in erviewed an adolescen emale who iden ied as m

(or, more accura ely, as a emale- o-male ransgender person). Wal ers in viewed his paren s and hey shared he challenges hey aced, par icula

or he mo her in erms o wan ing his o resolve in a way ha would her daugh er o her. Tese are hear breaking s ories and challenging oreveryone involved.

In response o his increased coverage, I asked he ques ions above: When child is gender dysphoric, how should paren s respond? Should paren s raise a

gender dysphoric child in he iden i y o he child’s biological sex? Should acili a e cross-gender iden ica ion? Or should hey ake a “wai and see” po wi h he assump ion ha he righ direc ion or ha child is wha will u

In addi ion o ques ions abou gender dysphoric children, Wha are hobliga ions or employers who have ransgender employees? How should ba hrooms be designa ed? Should medical coverage ex end o hormona

rea men and sex-reassignmen surgery? Wha abou room assignmen scampgrounds and a colleges and universi ies? Wha abou hiring policies churches, ai h-based minis ries, and a Chris ian colleges and universi ies

As churches consider rela ing o a drama ically changing cul ure, wha sshould be aken o reach unchurched persons who iden i y as ransgender o who are par o he ransgender communi y? Are here specic s eps





could be considered o accommoda e he experiences o gender dysphoricpersons who visi churches?

In all o hese discussions i should be no ed, oo, ha he ransgender ex-perience is no one experience; i is bes unders ood as an umbrella erm or

he many ways in which people migh experience heir gender iden i ies di -eren ly rom people whose gender iden i y is congruen wi h heir bir h sex.

Te experiences vary considerably and are only ma ched by presen a ion andexpression or he living ou o one’s gender iden i y, which can range rompushing agains gender norms (gender “bending”) o cross dressing or sexualarousal o show/per ormance/ en er ainmen (drag) o ranssexuali y.

Te ransgender communi y, hen, is broadly dened, and i has posi-ioned i sel alongside sexual minori ies in he broader cul ural discourse.

Sexual minori ies are people who experience heir sexual iden i y in waysha are differen han hose in he majori y (gay, lesbian, bisexual). When

we speak o sexual minori ies, hen, we are ypically re erring o how peoplenaviga e sexual iden i y and convey heir sexual pre erences o hemselvespriva ely or o o hers publicly (e.g., requen ly using he sel -dening atri-

bu ion “I am gay”).o en er in o an in ormed discussion o ransgender issues is o swi ch

gears a litle away rom a discussion abou sexual orien a ion. We can re urno i , bu i is no he ocal poin in he way i is when discussing homosexuali y

he erosexuali y and bisexuali y.o discuss being ransgender is o discuss one’s experience o gender

iden i y, one’s sense o onesel as male or emale, and how ha psychological

and emo ional experience is no aligning wi h one’s bir h sex.BACKGROUND

o begin o unders and gender dysphoria, i can be help ul o back up anddiscuss a broader con ex based on our unders anding o sex and gender. When we re er o a person’s sex, we are commonly making re erence o hephysical, biological and ana omic dimensions o being male or emale.5

Tese ace s include chromosomes, gonads, sexual ana omy and secondarysex charac eris ics.

Sex is requen ly dis inguished rom gender. Gender re ers o he psycho-logical, social and cul ural aspec s o being male or emale. When we re er osomeone’s gender iden i y, we are hinking o how a person experiences him-





or hersel (or hinks o him- or hersel ) as male or emale, including how mculine or eminine a person eels. Gender iden i y is ofen associa ed wigender role. Gender role, hen, re ers o ways in which people adop cul urexpec a ions or maleness or emaleness. Tis includes bu is no limi ed academic in eres s, career pursui s and so on.

For mos people, hese various ace s or dimensions o sex and gender aliin ways ha are essen ially aken- or-gran ed reali ies. Mos people you me have a rela ively unremarkable experience (or remarkable in he sense o

all o hese ace s coming in o alignmen ) o being born male or emale (whe alignmen o he various biological/physical/ana omical ea ures no

above), iden i ying as a man or a woman, and eeling masculine or eminin wi hin he cul ural con ex in which hey are raised.

Bu varia ions occur in hese areas. For example, here is likely grea er vabili y in how masculine or eminine a person eels, and ha is ofen a rec ion o whe her hey are reared in an environmen wi h rigid gender ro

and how well ha person’s experiences line up wi h hose expec a ions.Tese varia ions occur in o her areas as well and are ofen discussed as in-ersexuali y or an in ersex condi ion.6 In he area o biological/physical/ana-omical sex, we can no e several devia ions rom he norm o being born m

or emale. For example, a ormer clien o mine had been diagnosed wi

KEY TERMS

Biological sex : As male or female (typically with referenceto chromosomes, gonads, sex hormones, and internal repro-ductive anatomy and external genitalia).

Primary sex characteristics : Features that are directly partof the reproductive system, such as testes, penis and scrotumin males, and ovaries, uterus and vagina in females.

Secondary sex characteristics : Have no direct reproduc-tive function, for example, facial hair in males and enlargedbreasts in females.

Gender: The psychological, social and cultural aspects of be-ing male or female.

Gender identity : How you experience yourself (or think ofyourself) as male or female, including how masculine or femi-nine a person feels.

Gender role : Adoptions of cultural expectations for malenessor femaleness.





Kline el er Syndrome, a gene ic disorder o gonadal differen ia ion in whichha person had an ex ra X chromosome (XXY).7 Ano her person could be

born wi h ei her incomple e or mixed ovarian and es icular issues, a con-di ion ha has ofen been re erred o previously as rue hermaphrodi ism.8

Table . . 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 sexcharacteristics

Greater muscle mass, etc. Wider hips, enlarged breasts, etc.

A riend o mine has ye ano her physiological condi ion androgen insen-si ivi y syndrome as a resul o mal unc ioning gonads and o her prena alconcerns. Al hough she does no choose o iden i y as in ersex, many o heseindividuals would describe hemselves ha way, re erring o any number o varia ions rom he norm ha make iden i ying as male or emale problema ic.

Table . . Understanding Sex and Gender

Biological sex Male Female

Gender identity Man Woman

Gender role Masculine Feminine

Where do gender iden i y concerns in o all o his? I loca ed androgynyin be ween man and woman as gender iden i y. Androgyny can re er o nohaving a clearly dened sense o sel as a man/woman, or i can re er o a bringing oge her o male/ emale quali ies or charac eris ics.

Table . . Exceptions to Binaries

Biological sex Male Intersex Female

Gender identity Man Androgyny Woman

Gender role Masculine Outside cultural norms Feminine

Tis book is abou an experience ha is differen rom wha I have beendiscussing so ar, al hough here are elemen s o biological sex, gender role





and gender iden i y ha are all impor an in he discussion. Gender idenconcerns or wha we re er o as gender dysphoria re ers o experiences o

gender iden i y in which a person’s psychological and emo ional sense ohemselves as emale, or ins ance, does no ma ch or align wi h heir bir

as male. Tis would be he more common presen a ion, bu he reverse mayalso be experienced: a person’s psychological and emo ional sense o hemselves as male does no ma ch or align wi h heir bir h sex as emale.

Our illus ra ion changes, hen, o some hing ha does challenge he bin bu i does so no by residing in be ween he wo experiences o man/womra her, he experience loca es i sel in he o her (psychologically/emo ionain ways ha are ofen qui e difficul o ully unders and or empa hize wi

Dysphoria means being uneasy abou or generally dissa ised wi h somehing. Tus, gender dysphoria re ers o he experience o having a psychologic

and emo ional iden i y as ei her male or emale, and ha your psychologand emo ional iden i y does no correspond o your biological sex his peceived incongrui y can be he source o deep and ongoing discom or . Spec

cally, gender dysphoria, is on he one hand he experience o being born male(biological sex) bu eeling a psychological and emo ional iden i y as emSimilarly, gender dysphoria is he experience o being born emale (biologicasex) bu eeling a psychological or emo ional iden i y as male. When a persexperiences gender incongruence and i is causing hem signican dis ress oimpairmen , hey may mee cri eria or he diagnosis o Gender Dysphoria9

However, as we broaden he discussion o ransgender issues, we begin oex end he discussion beyond merely he experience o gender dysphoria, aexperience ha migh be charac erized by gender incongruence in which hperson does no experience an aligning o bir h sex and psychological senseo gender. ransgender is an umbrella erm or he many ways in which peoplmigh experience and/or presen and express (or live ou ) heir gender iden

Gender Identity Man Gender Dysphoria Woman

Figure . .





KEY TERMS

Gender dysphoria : The experience of distress associatedwith the incongruence wherein one’s psychological and emo-tional gender identity does not match one’s biological sex.

Transgender : An umbrella term for the many ways in whichpeople might experience and/or present and express (or liveout) their gender identities differently from people whosesense of gender identity is congruent with their biological sex.

Cisgender : A word to contrast with transgender and to sig-nify that one’s psychological and emotional experience ofgender identity is congruent with one’s biological sex. 10

Gender bending : Intentionally crossing or “bending” genderroles.

Cross-dressing : Dressing in the clothing or adopting thepresentation of the other sex. Motivations for cross-dressingvary significantly.

Third sex or third gender : A term used to describe personswho are neither man nor woman, which could reference anintermediate state or another sex or gender or having quali-ties of both man/woman in oneself.

Transsexual : A person who believes he or she was born inthe “wrong” body (of the other sex) and wishes to transition(or has transitioned) through hormonal treatment and sex-reassignment surgery.

Male-to-Female (MtF): A person who is identified as male atbirth but experiences a female gender identity and has or isin the process of adopting a female presentation.

Female-to-Male (FtM): A person who is identified as femaleat birth but experiences a male gender identity and has or isin the process of adopting a male presentation.

Genderfluid : A term used when a person wants to conveythat their experience of gender is not fixed as either male/ female but may either fluctuate along a continuum or encom-pass qualities of both gender identities.

Genderqueer : An umbrella term for ways in which peopleexperience their gender identity outside of or in between amale-female binary (e.g., no gender, genderfluid). Some peo-ple prefer a gender-neutral pronoun (e.g., “one”).

Drag queen: A biological male who dresses as a female (typi-

cally flamboyant dress and appearance) for the purposes ofentertaining others. Such a person may not experience gen-der dysphoria and does not tend to identify as transgender.

Drag king: A biological female who dresses as a male (ste-reotypic dress and appearance) for the purposes of enter-





i ies differen ly rom people whose sense o gender iden i y is congruen heir biological sex. A person could be under he ransgender umbrella and be gender dys-

phoric (experiencing signican incongruence ha is dis ressing). Ano heperson could cross-dress and nd he ac o cross-dressing sexually arousin(bu hey migh no experience he gender dysphoria he o her person por s). S ill ano her person could cross-dress wi h a s rong desire o s armonal rea men wi h an eye or sex-reassignmen surgery. Ye ano her pecould do drag shows and be qui e amboyan in presen a ion (e.g., drag queeor drag king), which may have litle i any hing o do wi h a subjec ive ex

rience o dysphoria or a desire or sexual arousal. Ta person would unlikelyiden i y as ransgender, al hough some migh , and ha person’s decisicould be ied o mo iva ions o cross-dress in his manner.

I should be no ed ha no every expression o gender variance dened he sidebar would repor gender dysphoria. Mos people who have an in erse

condi ion, or ins ance, do no experience gender dysphoria, al hough hhave a higher incidence ra e han hose who do no have an in ersex condi iand many would repor going hrough a ime o naviga ing gender idenques ions.11 Likewise, mos people who per orm in drag would no reporgender dysphoria as such and may no iden i y hemselves as ransgendernor would hose who do iden i y as ransgender necessarily consider hos who per orm drag o be ransgender.

taining others. As with drag queens, such a person may notexperience gender dysphoria and does not tend to identifyas transgender.

Transvestism : Dressing or adopting the presentation of theother sex, typically for the purpose of sexual arousal (and mayreflect a fetish quality). Such a person may not experiencegender dysphoria and may not identify as transgender. Mosttransgender persons do not cross-dress for arousal and seetransvestism as a different phenomenon than what they ex-perience.

Intersex : A term to describe conditions (e.g., congenital ad-

renal hyperplasia) in which a person is born with sex charac-teristics or anatomy that does not allow clear identification asmale or female. The causes of an intersex condition can bechromosomal, gonadal or genital.





I you are beginning o ge he sense ha his could ge complica ed, youare no alone. Tis is an area ha requires ime and pa ience o unpack and

ruly unders and and even hen, we do so wi h humili y given how much we do no know a his ime. Bu he church is going o need o spend some

ime on his opic. I urge church leaders o spend ime in care ul reec ion as we hink abou he bes way o engage he broader cul ure rom more o amissional approach while simul aneously considering how o come alongsidepeople wi hin our own Chris ian communi ies who are naviga ing his errain.

TOWARD A REASONED RESPONSETis brings us back o he person. I am hinking here o he person who isnaviga ing gender iden i y ques ions in his or her li e. I am hinking o heperson who experiences gender dysphoria. Ta experience o gender incon-gruence he experience o biological sex and psychological experience ogender no aligning can also be experienced along a con inuum. In o her words, gender iden i y concerns are no one hing experienced in exac ly hesame way by all people everywhere who experience i . a her, hink abou heexperience o incongruence and dis ress/discom or reec ing differen de-grees o bo h incongruence and discom or .

Wha is he bes way o proceed or he person who experiences genderdysphoria? Te remainder o his book akes ha in o considera ion, bu leme ou line a ew hings or us o consider as we move in he direc ion o amore hough ul response.

Le ’s consider wha we have said so ar: he person is naviga ing gender

iden i y concerns. Tese concerns are real and ofen qui e con using and iso-la ing. Te person worries abou who would believe hem, wha people wouldhink abou hem, and so or h. Tis is remendously isola ing and ofen asso-

cia ed wi h o her concerns, such as depression and anxie y. One reviewer shared wi h me ha she had a good riend who cross-dressed and abused a signicanamoun o alcohol o suppress her dysphoria; she shared ha he subs anceabuse aba ed once her riend was able o come o a place o congruence.

Tis is also no a par icularly common concern. Mos people experience aremarkable alignmen o he many ace s ha make up biological sex and heirsense o hemselves as male or emale. Bu or hose who experience genderiden i y conic s, he church will need o consider how bes o respond.

A he level o he individual, i can be help ul o ask a simple ques ion, such





as: How is he gender iden i y conic experienced by his person? Invi e person o ell you more abou heir experiences.

Keep in mind, oo, ha he person is naviga ing gender iden i y ques iin a cul ural con ex in which many people will respond o hem ou ocul ure war men ali y. No one naviga es gender iden i y concerns in a vacuu

a her, each person who aces his unique challenge does so in a sociocul ura

con ex in which sex and gender are being discussed and deba ed. As I men ioned earlier, some people are capi alizing on discussions in his

area o decons ruc sex and gender. I will discuss his in grea er de ailchap er wo. David Kinnaman o he Barna Group, in discussing gay marriagand reec ing on our rapidly changing cul ure, observed ha

he da a shows ha evangelicals remain coun ercul ural agains a rising ide opublic opinion. I he sands have shifed under evangelicals’ ee in he las

years, we a Barna predic i will seem he ground has comple ely opened be-

Figure . .

How is the genderidentity conictexperienced by

this person?

Gender Dysphoria

Figure . .

Gender DysphoriaThese concerns arebeing navigated ina specic cultural

context.





nea h hem during he nex . In par , ha ’s because he very belie ha same-sex rela ionships are morally wrong is deemed by many o be discrimina ory

and bigo ed.12

Tis commen by Kinnaman is in re erence o same-sex sexuali y, bu heoverarching discussion is abou LGB issues in general. In o her words, hecul ural opinion surrounding gay marriage represen s a broader cul uralopinion ha ex ends o ransgender issues and gender varian persons. Tesecul ural shifs requen ly rigger a response rom social conserva ives oconcern and, in some cases, ear or he erosion o long-held norms. Tese

batles are played ou in poli ics, en er ainmen , he media and educa ion. Teperson you are alking o is unlikely involved in hese spheres bu may simply be looking or suppor as hey naviga e his errain.

As Chris ians provide care o people in a sociocul ural con ex charac-erized by ideological and poli ical batles, we need o hink abou rising abovehe cul ure war when providing minis ry and meaning ul pas oral care and

suppor . We keep i in view (i is inescapable) while we provide services andcompassiona e care.

Why is his impor an ? Tere is good reason o believe ha he nex gen-era ion o Chris ians ends o value a rela ional e hic ha does no sacricerela ionships even when drawing dis inc ions in e hics and morali y:

Te Chris ian response o hese issues [marriage, e hics, human ourishing,and so on] has o be roo ed in a deeply rela ional e hic ha sexuali y is a re-la ional and in erconnec ed aspec o our humani y. Ta rela ionships mater,including hose be ween people who disagree.13

We will wan o keep his in mind, and his book is in ended o respec hashif in how discussions are carried ou be ween people where here is dis-agreemen , bu i is a leas impor an o recognize his cul ural shif amongChris ians.

Un or una ely, one way people respond o ransgender issues is o devaluehe person who is gender varian and simul aneously urn o rigid s ereo ypes

o gender. Ta reac ion is no only overly res ric ive, bu i can crea e a orced

choice or hose who do no in o hose rigid ca egories. I won’ be help ulo s ress s ereo ypes ha people are unable o adop . Also, keep in mind ha

we have wi nessed a cul ural shif ha may con ribu e o grea er uncer ain yaround sex and gender.14





Also, I will share la er some hough s and sugges ions on wha i looks o live ou various expressions o gender iden i y concerns, bu genera

speaking, I can see he value in encouraging individuals who experiencegender iden i y conic s o resolve he conic s in keeping wi h heir biri possible. Where hose s ra egies have been unsuccess ul, I recognize po en ial value in managing he gender iden i y conic or concern hrou

he leas invasive means (recognizing surgery as he mos invasive s ep owexpression o one’s in ernal sense o iden i y). I will come back o his, warran s more aten ion. Tere is a risk, oo, wi h so much media aten ion

ocusing almos exclusively on ranssexuali y while here are many o hepressions and experiences o ransgenderism and gender variance. I will say

his or now:Given he complexi ies associa ed wi h hese issues and he po or many and varied presen a ions, pas oral sensi ivi y should be a priori.

Also, I know many people who are naviga ing gender iden i y concerns who love Jesus and are despera ely seeking o honor him. I hink i would ba mis ake o see hese individuals as rebellious (as a group) or as projecSome do iden i y as ransgender or use o her labels or ways o naming h

reali y, and I would like he church o provide a suppor ive environmen hem as hey naviga e his difficul errain.

a her han rejec he person acing such conic s, he Chris ian cmuni y would do well o recognize he conic and ry o work wi h person o nd he leas invasive ways o manage he gender iden i y conceI will re urn o his principle hroughou he book, bu he idea is ha are many ways in which a person who experiences gender iden i y concerns

along a con inuum migh manage experiences o gender dysphoria. Jus as experiences reside along a con inuum, so oo do he possibili ies or expra ion o iden i y and managemen o wha con ribu es o gender dysph

CONCLUDING THOUGHTSGender iden i y concerns remain one o he mos complex and difficul

ully unders and. We know so litle abou he e iology and bes course o chough here are s rong proponen s or differen heories and approaches, ahere is division among men al heal h pro essionals on some impor an poin

and be ween some men al heal h pro essionals and some members o hransgender communi y. We will discuss each o hese issues in grea er de

in subsequen chap ers.





When he opic o rea ing gender dysphoric children is brough up, somepro essionals ocus on resolving gender dysphoria o reach congruence wi h he

child’s bir h sex. Tis has been increasingly viewed wi h skep icism; vocal cri icsrom he ransgender communi y have expressed how his is no unlike con-

version herapy or homosexuali y. Also, once a child reaches la e adolescenceor adul hood, here are ew large-scale s udies o psychosocial in erven ions

oward his end, and even less op imism or such a resolu ion once a person hasreached adul hood. Perhaps as a resul , he eld has moved in he direc ion osuppor or hose who wish o pursue cross-gender iden ica ion, wi h severalmodels ha ei her “wai and see” or acili a e such cross-gender iden ica ion

hrough puber y suppression. Once a person reaches adul hood, considera ionis hen given o medical in erven ions o acili a e cross-gender iden ica ion,and hese may include hormonal rea men and sex-reassignmen surgery.

As we close his chap er, I wan o poin ou ha here has been one s udypublished o male- o- emale ransgender Chris ians.15 I no ed conic s wi hgender iden i y and religious iden i y in erms o personal ai h, God and helocal church.16 In eres ingly, some ransgender Chris ians shared ha heir

gender dysphoria led o as reng hening o heir personal ai h; o hers repor eda pas s ruggle wi h heir ai h, and s ill o hers lef he organized religion wi h which hey grew up. For some, he challenges hey aced brough hem closer

o God, bu o hers repor ed a s rained rela ionship wi h God because o heirgender dysphoria. Par icularly common was pas conic wi h he localchurch communi y or he persons and leaders who represen hese organiza-

ions. I will re urn o his s udy hroughou his book, as some o he in or-

ma ion shared in ha con ex may in orm our broader discussion.I is unclear o me a his ime whe her here is any one ou come ha isul ima ely sa is ying o everyone who has a s ake in hese discussions. I issuch a rare condi ion ha we have litle good research rom which o draws rong conclusions, and I have known people who el gender dysphoria sos rongly ha hey el no hing less han heir sani y and heir li e was a s akTey despera ely sough a resolu ion o he dysphoria ha caused hem sig-nican dis ress and impairmen . Tis is no an argumen ha hey shouldpursue he mos invasive procedures, bu we also acknowledge ha we under-s and and empa hize wi h ha decision, as pain ul as i ofen is. a her hanrejec he person acing such conic s, he Chris ian communi y would do well o recognize he conic and ry o work wi h he person o nd he leas





invasive ways o manage he dysphoria. Perhaps u ure programs o resear will provide grea er insigh and clari y in o an area ha seems par icularl

cul o naviga e a his ime. Tese include bu are no limi ed o researche ypes o resolu ions sough by people wi h an eye or he developme

considera ions associa ed wi h gender dysphoria in childhood, adolescenceand adhul hood, how s reng h o gender dysphoria is rela ed o various

emp ed resolu ions, he role o personal values and religious ai h commmen s in seeking resolu ions, and so on. Tere is an oppor uni y here o learnmuch more han we know a presen , and we would do well o en er in o discussion wi h pa ience and humili y as we balance mul iple perspec ives how bes o resolve wha people ofen repor o be an impossible si ua ion




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understanding gender dysphoria by mark a. yarhouse - excerpt

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