Understanding Gender Dysphoria, page 10
It could be that for some people a very narrow window exists in which the causes of gender incongruence are largely biological as the brain-sex theory suggests, while for most other people who report gender identity concerns, experiences of gender identity conflicts come from other, more varied sources that are weighted differently for different people, thus contributing to the wide range of gender variant presentations. For less severe gender identity presentations, perhaps the biological contributions take the form of temperamental and personality differences or sensory reactivity, followed by environmental conditions and social learning, among other factors, including but not limited to parental preferences, indifferences, reinforcement and modeling.71 For some people, the biological contributions could be weighted even more, perhaps even to the point suggested by the brain-sex theory.
Other factors may be difficult to identify as clearly from nature or from nurture; they interact. For example, a biological male who has a feminine appearance may have such an appearance due to nature, but the environment and how others interact with him may also make a significant contribution. Similarly, insecure attachment may come from contributions from nature but also from environment, as when a child experiences insecure attachment as a result of abuse.
Concluding Thoughts
I have been told, “If you know one transgender person, you know one transgender person!” In other words, there are so many variations in experience and presentation that knowing one transgender person tells you very little about transgender persons as a group. That may be true. Important questions remain about etiology, and we have already established that the transgender umbrella is quite broad. I am not optimistic that one unifying theory will explain the myriad presentations that exist under that particular canopy.
What I have been able to conclude about etiology is exactly what I told Jeremy and recounted at the opening of this chapter: “I don’t think you chose to experience gender dysphoria.” At some point in my work with a person who experiences gender identity conflicts, I will ask something like this: “What would it mean for you to know?” In other words, “What is the significance to you personally of having a working theory of causation?” Part of what I am saying is this: “How would I know if you experienced gender dysphoria due to various contributions from nature or key events in your environment (nurture)?” I would not be able to be certain. Neither will the person who is navigating gender identity concerns. I keep in mind that most people do develop a kind of storyline for themselves for their experiences of gender dysphoria. We can discuss that storyline, as well as other possible narratives, without the clinician imposing one on the client. It can be a kind of personal, working hypothesis, and it may not be the same for the client and for the clinician.
Another question for reflection is this: What is volitional here? A person can choose whether to engage in cross-gender behavior (or, to a lesser extent and to remind us of the continuum, gender bending behaviors of one kind or another). The experience of true gender dysphoria, however, is not chosen, nor is it a sign of willful disobedience, personal sin or the sin of the parents as such.
What can be difficult to discern is what kind of gender identity conflict we are witnessing. With the many ways in which a person can experience gender identity concerns (organized by onset; organized by sexual orientation; organized by purpose of cross-dressing or meaning, or other factors), how does this person’s cross-gender interests fit into a larger meaning-making structure for this person? We can distinguish between those who bend gender roles in dress as a way of forming a sense of distinct and countercultural identity from those who are expressing their sense of their “true” self from those who are managing a dysphoria they wish would abate. Along these lines, it seems different to think about cross-dressing for sexual arousal and cross-dressing to manage gender dysphoria. It seems different to think about cross-dressing behavior as performance (i.e., drag) and cross-dressing to express one’s core sense of self.
When I think of also considering a Christian worldview, it is important to reflect on our integrated framework first discussed in chapter two. Recall that an integrated framework looks at the strengths of three existing frameworks: the integrity framework, the disability framework, and the diversity framework. The brain-sex theory and related models reflect more of a diversity framework in which gender identity issues are merely a reflection of variations in nature across the various factors that are involved. It could reflect a disability framework to some extent, but most adherents do not use language that would suggest that; perhaps some proponents of the brain-sex theory would consider a disability framework if the dysphoria were causing distress and disruption in various social roles.
Proponents of Blanchard’s typology seem less certain of a causal pathway. I do hear more of a concern among some proponents of Blanchard’s typology that gender dysphoria can function like a disability—again, insofar as the condition causes a person social distress and impairment. Zucker’s view also seems concerned about the gender dysphoria in and of itself as a reflection of a disability of sorts as a person is longing for quite invasive interventions to express cross-gender identification and to resolve gender dysphoria.
An integrated framework would reflect some regard for all three of these explanatory frameworks. Let’s at least begin here in our discussion of etiology.
The integrity framework reminds us that God had a purpose in creating humankind male and female. We take seriously our biological sex and our gendered selves and how our sex and gender are parts of how we experience ourselves and relate to one another. Experiences like gender dysphoria, while they might be considered variations along the lines suggested by brain-sex theory, also exist in the context of a fallen world. The integrated framework also reminds me that because we live in a fallen world, questions about etiology are essentially questions about specific ways in which the fall casts its shadow all around and through us—in this case how the fall touches sex and gender in unique and uncertain ways. Also, the integrity framework gives us pause when we might otherwise focus on celebrating a gender dysphoria as though it were an expression of diversity as such or using such experiences to deconstruct sex and gender as though biological sex was an arbitrary source of oppression.
A disability framework reminds us of the benefits seen in viewing gender identity concerns as morally neutral. Keep in mind that the person who is navigating these concerns has not chosen to experience dysphoria. The incongruence between their biological sex and their gender identity is, in and of itself, not an act of willful disobedience. When we consider how best to care for someone who is navigating gender identity concerns, we can respond with compassion, keeping in mind that the person we are meeting with will face some painful and unique challenges in managing their dysphoria, which we will discuss in greater detail in chapter six.
The diversity framework emphasizes the variation as a cause for identity and for recognition and celebration. The identity comes in being transgender or in adopting a cross-gender role through any number of ways of expressing one’s true self. The recognition and celebration can come from many different theories of etiology, although I suspect many proponents of a diversity framework are less concerned with theories of etiology and might be more concerned if a theory were to be used to further marginalize or pathologize a people group. Those who adopt a diversity framework likely do not know a specific causal pathway, but they might adopt a brain-sex model insofar as it can register as a model of identity in keeping with essentialist assumptions that help a group’s cause in the broader cultural discussion and popular perception of transgender persons. The diversity framework may bias us toward the brain-sex theory over the others, so we want to consider any theory of etiology with humility about what we know and do not know at this time.
How we provide services to someone and address fundamental issues of identity and community, however, should be informed by a nuanced understanding for how the existing diversity framework provides significant meaning and purpose that is often not found in the Christian community when it comes to the care and counsel of those who experience gender dysphoria.
4
Phenomenology and Prevalence
The phenomenology and prevalence of gender incongruence are related in part because the range of gender variant expressions and identities makes finding accurate prevalence estimates a challenge. In some respects, prevalence estimates were relatively clearer under the prior designation of Gender Identity Disorder. The change to Gender Dysphoria broadened the definition and scope of what may count as a gender identity concern. Also, I use the phrase “relatively clearer” because there were problems obtaining prevalence estimates with Gender Identity Disorder, too, as I will discuss below. Also, there are cultural expressions that are more common, such as cross-dressing behaviors for sexual arousal or as a fetish and various gender “bending” behaviors that are not quite the same thing as gender incongruence.
It has been helpful to many people to think about gender identity issues along a continuum. Gender dysphoria has been defined as “unhappiness with one’s given gender.”1 This is not just feeling unhappy with being either male or female; nor is it identifying advantages to being the other sex. It is a more substantive “unhappiness,” if you will, and it is a substantive unhappiness that leads to distress.
We can distinguish experiences of gender dysphoria from the diagnosis of Gender Dysphoria. When mental health professionals consider a diagnosis of Gender Dysphoria (which I will capitalize for the sake of clarity), they are saying that this “unhappiness with one’s given gender” has risen to the level of an enduring, significant cross-gender identification and personal distress or impairment in important areas of functioning, such as work or school.
Gender Dysphoria can be diagnosed in children, adolescents or adults as—in the language of one of the most widely read diagnostic manuals—a “marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months’ duration.”2
Gender Dysphoria in Children
When Gender Dysphoria is diagnosed in children, six of eight other symptoms would be present, and one of those symptoms has to be the first one on the list (“A strong desire to be of the other gender or an insistence that one is the other gender”). Symptoms include:
A strong desire to be of the other gender or an insistence that one is the other gender.
In boys (assigned gender), a strong preference for cross-dressing or simulating female attire; or in girls (assigned gender), a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing.
A strong preference for cross-gender roles in make-believe play or fantasy play.
A strong preference for the toys, games, or activities stereotypically used or engaged in by the other gender.
A strong preference for the playmates of the other gender.
In boys (assigned gender), a strong rejection of typically masculine toys, games, and activities and a strong avoidance of rough-and-tumble play; or in girls (assigned gender), a strong rejection of typically feminine toys, games, and activities.
A strong dislike of one’s sexual anatomy.
A strong desire for the primary and/or secondary sex characteristics that match one’s experienced gender.3
These experiences in a child would also be distressing to the child or would be impairing in an important area of functioning, such as school.
My experience has been that many Christians respond negatively to the language of “assigned gender.” As I will discuss below, Christians are not alone in expressing reservations about this change in language and conceptualization. This change in the DSM-5 was meant to include those who are intersex, that is, those who have a condition that makes it difficult to identify their sexual anatomy at childbirth. In cases in which this occurs, the gender has often been assigned by the doctor or by the parents in consultation with a medical team and sometimes with disastrous results. The book As Nature Made Him documents the case of a baby boy who underwent a botched circumcision and who was raised as a girl at a time when some experts were quite confident that social learning could trump biology.4 The boy, John, was actually unable to sustain an identity as a female (Joan) and transitioned to male in adolescence. Tragically, as an adult he took his own life.
When we think about “assigned gender,” the phrase is meant to remind us of these kinds of intersex experiences—whether as a result of a mishap at the time of circumcision or a medical condition such as Androgen Insensitivity Syndrome. The point here is that this is probably not how most Christians think about being identified as a boy or girl at birth. Most parents do not think in terms of “assigned gender.” Other phrases that are frequently used would be “natal gender,” “birth sex” or “biological sex.” A case could be made for each of these phrases, and professionals in the field demonstrate a preference for any one of these phrases today. The language is meant to communicate to the reader that in the experience of gender dysphoria there exists a contrast between that assigned/natal/birth/biological gender/sex and the child’s “experienced” or “expressed” gender. It is that lack of congruence or correspondence that is part of what is being assessed.
The challenge that exists in making this kind of diagnosis in a child is distinguishing between experiences of gender atypicality, in which a child might behave outside of gender norms or stereotypes, and when a child truly expresses a kind of gender incongruence that warrants a diagnosis. In other words, many children may be “subthreshold,” or below the threshold of a diagnosis.
Also, situation/context is critical. I have met with boys who have a sister near their age and only have girls in their immediate neighborhood. Their play is often with girls. This alone would not be considered a strong preference for playmates who are girls, so that has to be differentiated.
The mother of a six-year-old Caucasian boy calls for services. She reports concern about his mannerisms and voice inflection—that it is more effeminate—and she fears he will be teased in school. She has already had family members and people at the park comment on his mannerisms.
The mother and father report that their son’s cross-dressing started at age three and that he would also play dress up as a female at his friend’s house. They noticed female gestures and mannerisms at age five (e.g., hand on hip, wrist). They indicated his play group was primarily females.
His parents confirmed that their son stated that he wished God had made him a girl. They reported consistent identification with his mother, stating that he wanted to be like her, and little identification with his father or older brother.
I have at times seen a lack of identification with the same gender parent among those children whose parents report a gender identity concern. Many boys who do not have a history of gender identity conflicts will identify with their father and name ways in which they are similar. If a boy sees his father come out of the shower, he might say, “Dad, you have a penis like I have a penis!” There is a sense in which he sees in his father aspects of himself, and vice versa.
Not only can that be absent in a child who experiences gender dysphoria, but the identification seems to be with the adult figure of the other sex. In the case above, I mentioned that the six-year-old tended to identify with his mother. What does that even mean? For this particular boy, he would grab a towel and wrap it around his head, letting the length of the towel go down his back. He would exclaim, “I have long hair just like you, Mom!” Or he would wrap a towel around his waist as though it was a skirt or a dress and say, “I have a dress on just like you, Mom.”
Here is the challenge: many kids may do something like this, and they are not Gender Dysphoric in the diagnostic sense, and they might not be particularly gender dysphoric in the broader sense of the term. They are playing; they are finding ways to connect with their mom or dad. That is one reason why a diagnosis is not made without identifying several ways in which a child expresses symptoms of Gender Dysphoria.
This is probably the most difficult distinction to communicate to people who have not worked with children who meet criteria for Gender Dysphoria. They will say, “Every child I know plays like that from time to time. It’s not that unusual.” Yes and no. While not all children engage in cross-sex-typed play, some do, so from that standpoint, I agree with the idea that it is not that uncommon. Certainly a diagnosis should not be made on that fact alone. However, when a child is truly gender dysphoric, the play means something different to that child than to a child who is not diagnosed with Gender Dysphoria.
In a study of children who presented with Gender Dysphoria, Steensma et al.5 distinguished between those children whose dysphoria persisted into adolescence and those children whose dysphoria resolved. A biological male whose gender dysphoria persisted shared the following: “I always played with girls’ stuff and I dressed up as a girl. I sometimes borrowed my sister’s dress and had a furry sheet, which I tied on my head, pretending I had long hair.”6 A biological female whose gender dysphoria persisted shared the following: “The girls played with Barbie dolls, wore dresses and they gossiped. I never gossiped. I usually decapitated Barbie dolls, when I got them, and threw them in the dustbin. I played soccer, wore blue jeans, and played with marbles. I played with the boys and I was always in the company of the other boys.”7
