Understanding Gender Dysphoria, page 12
Homosexual gender dysphorics maintain that their sexual interest in other men is actually heterosexual, because “inside” they really are women. They also prefer partners who are heterosexual—who claim to be so—and who concur with the transsexual’s self-evaluation that he is “really” a woman. Transsexuals, therefore, reject lovers who show an interest in their male genitals, not only because they hate their genitals to be touched in the first place, but also because they conclude (probably correctly) that these men are homosexual.32
The person presenting as Male-to-Female Autogynephilic Type is sometimes referred to as expressing the heterosexual or transvestic form because in some descriptions it appears as a kind of fetish. According to Blanchard,33 this person’s early history is not unlike that of others who present with tranvestism in that most are interested in gender typical male activities as boys; most experience some arousal when cross-dressing; they tend to work in more male-dominated professions/occupations, and so on. Richard Carroll34 also offers that, as a child, the heterosexual type presentation may have been more masculine. He would typically have dressed in his mother’s (or sister’s) clothing prior to puberty and found that arousing. He would typically report being attracted to females and often puts himself in almost hyper-masculine roles, such as weightlifting, law enforcement or the military. He is more likely to marry someone of the opposite sex. Over time, he may feel the need to transition to female, and this is considered the most common presentation among biological males seeking hormonal treatment and sex-reassignment surgery. According to proponents of this distinction, the psychology of male-to-female autogynephilia appears to be arousal at the thought/fantasy of oneself as female, which is where the fetish quality comes to the foreground. This client would likely be sexually attracted to women and would also fantasize/imagine himself as female. Carroll explains autogynephilia: “The term refers to the experience of sexual arousal (philia) to the fantasy of oneself (auto) as being a female (gyne).”35
Lawrence, in one of the most complete resources comprised of the personal narratives of autogynephilic individuals, refers to their experiences as “men trapped in men’s bodies,”36 by which she means to contrast their experience with the male-to-female androphilic presentation of being a “woman trapped in a man’s body.” The experience of the autogynephilic individual does appear to reflect “a sexual desire that accompanies the desire to be female.”37
Blanchard notes that for the male-to-female autogynephilic person (heterosexual or transvestic form), interest in cross-dressing often creates a conflict:
Many have realistic fears about their ability to “pass” as women; others fear having their anomaly discovered by their families, friends, or colleagues at work. A common compromise is going out in women’s attire for a solitary walk or drive, usually late at night when there are few people around. . . .
Whether or not he overcomes his fear of going in public cross-dressed, the heterosexual gender dysphoric is increasingly confronted with another, more serious problem: the frustrating conflict between his desire to live as a woman and his reluctance to abandon his wife, children, or career. This is the point at which these patients typically present for treatment.38
Blanchard hypothesized that there may be different manifestations of autogynephilic interests (behaviors and fantasies): “transvestic (involving wearing women’s apparel), anatomic (involving possessing female anatomic features), physiologic (involving having female physiologic functions), and behavioral (involving engaging in stereotypically feminine behavior).”39
Blanchard describes other clinical presentations of gender dysphoria, such as the bisexual gender dysphoric type (with a history of sexual arousal to the same and opposite sex) and the asexual/analloerotic type (with no or little arousal pattern).40 But these appear less frequently than the more common presentations noted above.
Early and Late Onset
I mentioned earlier that the DSM-5 has moved away from specifiers that focus on attraction or orientation, which are key aspects of Blanchard’s typology. Rather, the DSM-5 includes early and late onset as specifiers. These are generally thought to apply in particular to male-to-female transgender persons. In a helpful summary of the clinical evidence collected to date, Zucker and Brown describe the more common experiences and concerns of early-onset male-to-female transgender persons:
Early-onset [male-to-female transgender persons] often recount significant histories of social exclusion and harassment over long periods of time. They tend to have high degrees of social anxiety and may be less socially skilled on account of having lesser practice within peer networks. Some of this may be resolved through transition, but there is typically quite a bit of residual work regarding grieving the experiences they have missed out on, low self-esteem, and the anxiety of being discovered as trans, as early transitioners often choose to live “stealth” (i.e., not disclose their transition history to most others). If their families are not supportive, this group is much more vulnerable to homelessness, to using substances to cope, and/or to survival sex work.41
Zucker and Brown also offer a helpful description of male-to-female transgender persons who experience late-onset gender dysphoria:
Late-onset [male-to-female transgender persons] have mostly grown up with fairly traditional masculine childhoods and the psychological steadiness and resilience that acceptance and “fitting in” (at least from the outside) can bring. Contemplating transition is often frightening, as the stripping of privilege and potential losses in relationship and employment can be sudden and staggering. If they lose core parts of their lives, which many do, there may also not be an easy transition into new communities or employment opportunities. Many could be helped with great work and/or by finding new supports or activities.42
When we think of time of onset as a key distinction between how people might experience and present with gender identity concerns, we can distinguish between early onset and late onset. Early onset is the more common presentation, though it is likely to diminish or resolve in most people who experience it.
Concluding Thoughts
As I bring this chapter to a close, we should recognize that gender dysphoria that rises to the level of a diagnosable disorder (Gender Dysphoria) is quite rare. People may experience gender dysphoria or a kind of gender incongruence along a continuum, and the prevalence estimates likely rise when we start discussing the experience along these lines. Any continuum might include gender-bending behaviors among adolescents and young adults, which may or may not reflect gender dysphoria, as well as gender variant expressions and identities and the range of experiences under the transgender umbrella, such as persons who identify as genderfluid, genderqueer, cross-dressers, drag kings and queens, transvestites, and intersex. As I noted in chapter one, not everyone who is in each of these categories (e.g., drag king) would consider themselves transgender, and not all transgender persons would count each of these categories of people as belonging under the transgender umbrella. Certainly not all experience gender dysphoria. However, as we think about prevalence estimates, recent probability studies suggest prevalence is much higher when people are given the option of selecting “transgender” as an identifier than when we base prevalence on those who are formally diagnosed with Gender Dysphoria or who present at specialty clinics.
Also, it should not be underestimated that gender dysphoria, insofar as it may be experienced to varying degrees by many different kinds of people who fall under the transgender umbrella, represents an issue within our culture that is hugely symbolic. In the context of the social and cultural discussions and debates (and political wars) surrounding sex and gender and ethics, it represents to some an opportunity to challenge structures of authority that they have experienced as oppressive. To others it represents an effort to deconstruct meaningful designations of sex and gender. To still others it may represent great pain and hardship that seem to offer few satisfying pathways to resolution.
The Christian community faces a unique challenge in rising above the culture wars and these symbolic dimensions as we think about how to engage both the broader culture and the individual who is navigating gender identity questions. There remains the theological challenge associated with thinking clearly about sex and gender, debates about essentialism and social constructivism, and theological anthropology and ethics. There also remains the pastoral challenge of how to translate that theological work into the practical necessities and pastoral accommodations associated with compassionate care for the persons who are navigating gender incongruence in their lives.
5
Prevention and Treatment of Gender Dysphoria
“What can we do?” asked the mother of a seven-year-old boy. She looked up and caught my eye. “What should we do? Just last week a woman at the park said something. I couldn’t believe she had the nerve, but she did. I’m worried about him; I’m afraid that kids at school might do worse. There have been a few things said, at least he has hinted at a couple of things. But that could get worse. How they might tease him . . . I don’t know. . . .” The mother went on to describe her son’s effeminate behavior and mannerisms, as well as how his voice inflection seemed more like that of a girl’s. She spoke of his tendency to pretend he had long hair and declare, “Mom, I have long hair like you have long hair!” She shared that just this past weekend, he grabbed a towel and put it around his waist and said, “Look, Mom, I’m wearing a dress just like you!” And he would often put on her heeled shoes and walk around in them.
This was a challenging situation for the parents. They were unsure how to respond to their son. They did not know if this was a phase he was going through, although they hoped it was just that. They did not know if it was a sign that he was going to be gay. They did not know what gender incongruence or gender dysphoria was, so that was not even on their radar.
This chapter looks at ways in which professionals respond to gender dysphoria in childhood, adolescence and adulthood. The responses to childhood experiences of gender dysphoria are controversial and differ significantly from responses to adolescent and adult experiences of gender dysphoria.
In Childhood
Most cases of gender incongruence in childhood resolve by the time the child reaches adolescence or adulthood. That many desist in their experience of gender incongruence and dysphoria has been noted in recent research.1 It is also possible that gender incongruence is suppressed so that it is not seen or, in the case of a friend, repressed (outside of conscious awareness) and then comes back to his awareness several years into his marriage.
When we consider the possibility of gender dysphoria desisting, the debates center on whether the resolution occurs “naturally,” if you will, or if therapy can be provided to facilitate a reduction in gender incongruence and dysphoria. The most vocal critics of such practices demean it (and the professionals who provide it) as a version of conversion therapy, likening it to attempts to change sexual orientation. Outspoken critics of conversion or reorientation therapy often liken it to bleaching an African American’s skin in response to his or her own self-hatred and racial stigma.
Ideally these clinical issues will be answered through well-designed research studies of the likelihood of various interventions producing favorable results. Research, of course, provides us with information on what we are able to do; it does not answer questions about what we ought to do. That is a question for philosophical ethics and theology.
As we look at responding to childhood experiences of gender dysphoria, the four options here for discussion are
resolution of gender dysphoria through intervention to decrease cross-gender identification
watchful waiting
facilitation of the gender identity of the preferred sex in anticipation of an adult identification
intervention to block hormones until a child (now a teen) can decide about gender identity in later adolescence
The literature often distinguishes three options by essentially combining psychosocial facilitation of cross-sex identification with movement toward puberty suppression.2 However, I see these as two similar but different approaches. Although they share a common trajectory (toward facilitating cross-gender identification, i.e., the gender identity of the preferred sex), it should be noted that psychosocial facilitation can take place without the use of puberty suppressing hormones.
Table 5.1. Approaches to Childhood Experiences of Gender Dysphoria
Decrease
Cross-Gender
Identification
Watchful
Waiting
Psychosocial
Facilitation
Puberty
Suppression
Emphasis on resolution of Gender Dysphoria by decreasing cross-gender behaviors and identification. Take a neutral approach that allows for cross-gender dress and role adaption while avoiding reinforcement. Facilitating expression of a gender role that reflects a child’s gender identity. Use of puberty-suppressing hormones to delay puberty until an adolescent can decide about gender identity.
Decrease cross-gender behavior/identification. Those who provide interventions to resolve gender dysphoria by decreasing cross-gender behavior/identification frame their work as facilitating desisting what they believe will occur in most cases anyway.3 Proponents of early intervention also consider whether those whose gender dysphoria persists and those whose desists represent two different conditions. It is unclear whether those are two different issues at present, but perhaps future research will answer that question or at least provide greater insight. Also, proponents note that the known emotional and social correlates of gender incongruence—issues like family and peer conflict and ostracism, as well as depression, anxiety, school aversion and school drop-out—provide a rationale for intervention:
These sequelae . . . are our primary reason for its treatment. We expect that we can diminish these problems if we are able to speed up the fading of cross-gender identity which will typically happen in any case.4
There are, generally speaking, two broad approaches—behavioral and psychodynamic—with the more recent proposal for a third treatment approach. Behavioral therapy encourages the same-sex parent (or grandparent or mentor) to spend more time and share positive play experiences with their child while also avoiding criticism of the child. The parents are coached to essentially ignore cross-sex-typed behavior if at all possible and identify strategies to redirect the child to behaviors that reflect more that child’s gender.5 In following an operant conditioning approach, parents praise the child for any gender-appropriate activities or play.
Psychodynamic approaches (psychoanalysis, psychotherapy, psychoanalytic psychotherapy) based on object relations, self psychology and other conceptualizations take a developmental perspective, explore identification with the same and opposite sex, and intervene more “within” the child (than through the environment).6
Those who provide similar services today combine some of the approaches presented above into a hybrid or “third way” model.7 They extend the treatment beyond simple behavioral reinforcement by providing therapy to address a child’s gender incongruence and identity from the “inside out,” while also setting limits and providing education to address gender identity from the “outside in.”8 Parents are also provided assistance in identifying activities that facilitate a same-gender identification, and there is typically a significant increase in time spent with same-sex peers (milieu protocol) that has been shown in research to be associated with “more typical sex-differentiated behavior.”9
As I mentioned, one rationale for such intervention is the social climate and peer group disapproval that is associated with gender variant identity and behavior in elementary, middle and high school years.10 Another is that with intervention there does seem to be a decrease in the number of people who persist in their gender incongruence into adolescence and adulthood.11
Meyer-Bahlburg12 offers a protocol for intervention to facilitate the resolution of gender dysphoria among biological males. That protocol focuses on the following:
Fostering positive relationship with one’s father or male caregiver or role model
Fostering positive relationships with one’s male peers
Fostering gender-typical habits and skills
Facilitating male peer group interactions
Facilitating positive feelings about being male
This kind of protocol is rather eclectic, with aspects of social learning theory and behavioral and milieu therapy approaches. To reduce stigmatization, the protocol focuses on services to the parents who work with the child rather than work directly with the child. Other approaches include direct therapy with the child as well as work with parents and the school system.
There has been research conducted on outcomes with Gender Dysphoric children when intervention is in place to prevent dysphoria from continuing into adolescence and adulthood. For example, a National Public Radio report on the topic cited the Portman Clinic’s treatment of 124 children since 1989.13 The approach taken at the Portman Clinic is to have children live in a way that is consistent with their birth sex. It was reported that 80 percent of the children chose later as adults to maintain a gender identity consistent with their birth sex.
