Understanding Gender Dysphoria, page 15
These are sobering findings that raise the question of whether these more invasive procedures are the answer for transsexuality. Perhaps other options should be explore further. Perhaps indicative of the broader support for this direction of care in the mental health field, the authors of the study took the position that greater emphasis should be placed on aftercare and longer-term support following surgery: “Improved care for the transsexual group after the sex reassignment should therefore be considered.”68
Concerns About Sex-Reassignment Surgery
I distinctly remember the time I finished a talk I had given on sexual identity. I had been asked a question about gender identity (which is not uncommon after an extended discussion of sexual identity), and apparently my response raised more questions than answers. Two men in the audience came up to talk to me. The one introduced himself and his friend and shared with me that his friend had transitioned from male to female years ago, later became a Christian and eventually felt he needed to reclaim his identity as a male. The former male-to-female transsexual did not say much and seemed rather socially reserved, but we talked a little about the concerns he had as a new Christian that led him to conclude he needed to transition back.
I bring up this example to point out that not everyone is supportive of cross-gender identification with or without surgery. In the case of surgical procedures, though, people have articulated concerns about sex-reassignment surgery. Some concerns have to do with long-term outcomes and comorbidity, as noted above. Even here, however, many researchers are not so much questioning the surgery but the level of support provided after surgery is completed, suggesting an overall trend in professional support for hormonal treatment and sex-reassignment surgery.
However, the philosophical position that supports sex-reassignment surgery for gender dysphoria is not without its critics. For example, McHugh wrote a strong criticism of the practice of sex-reassignment surgery, pointing out that the fact that we can do such surgeries does not mean we ought to do such surgeries:
The skills of our plastic surgeons, particularly on the genito-urinary system, are impressive. They were obtained, however, not to treat the gender identity problem, but to repair congenital defects, injuries, and the effects of destructive diseases such as cancer in this region of the body.69
Indeed, McHugh goes on to suggest that psychiatry has essentially catered to individual preferences and cultural pressure—“fashions of the seventies that invaded the clinic”;70 he likens sex-reassignment surgery to liposuction for anorexics:
It is not obvious how this patient’s feeling that he is a woman trapped in a man’s body differs from the feeling of a patient with anorexia nervosa that she is obese despite her emaciated, cachetic state. We don’t do liposuction on anorexics. Why amputate the genitals of these poor men? Surely, the fault is in the mind not the member.71
McHugh elaborated on his argument in a more recent opinion piece in The Wall Street Journal:
The transgendered suffer a disorder of “assumption” like those in other disorders familiar to psychiatrists. With the transgendered, the disordered assumption is that the individual differs from what seems given in nature—namely one’s maleness or femaleness. Other kinds of disordered assumptions are held by those who suffer from anorexia and bulimia nervosa, where the assumption that departs from physical reality is the belief by the dangerously thin that they are overweight.72
A similar argument was brought up in the popular press. In an article that first appeared in the Chicago Sun-Times and was later retracted, Kevin D. Williamson wrote about sex-reassignment surgery. He was discussing Katie Couric’s interview of Laverne Cox, a transgender person who had been featured on the cover of Time magazine:
Regardless of the question of whether he has had his genitals amputated, Cox is not a woman, but an effigy of a woman. Sex is a biological reality, and it is not subordinate to subjective impressions, no matter how intense those impressions are, how sincerely they are held, or how painful they make facing the biological facts of life. No hormone injection or surgical mutilation is sufficient to change that.
Genital amputation and mutilation is the extreme expression of the phenomenon, but it is hardly outside the mainstream of contemporary medical practice. The trans self-conception, if the autobiographical literature is any guide, is partly a feeling that one should be living one’s life as a member of the opposite sex and partly a delusion that one is in fact a member of the opposite sex at some level of reality that transcends the biological facts in question. There are many possible therapeutic responses to that condition, but the offer to amputate healthy organs in the service of a delusional tendency is the moral equivalent of meeting a man who believes he is Jesus and inquiring as to whether his insurance plan covers crucifixion.73
In the final analysis, the argument from critics of sex-reassignment surgery as treatment for gender identity concerns is that more effort should be placed on prevention and management of gender dysphoria: “We have to learn how to manage this condition as a mental disorder when we fail to prevent it.”74
Another consideration has to do with whether we are providing the best care to those who have more of an autogynephilic presentation. They appear to be at greater risk for regretting the decision to pursue sex reassignment. Should there be a more complete assessment and nuanced decision tree around pursuing the most invasive treatment given the greater risk that it may not be gender dysphoria that is actually driving the request for surgery? The argument has been made by Lawrence75 in the other direction, that is, that perhaps a more nuanced assessment would allow for sex-reassignment surgery for those autogynephilic men who are actually unable to complete the full-time presentation as a female, thus giving greater weight to autogynephilic motivations.
As I mentioned, while there are critics of sex-reassignment surgery, the trend within the mental health field is toward such an intervention when indicated. However, most people who experience gender incongruence in adulthood do not undergo surgery. Most cross-dress intermittently either as an expression of their sense of gender identity or they use cross-dressing as a way to manage their dysphoria, among other possible motivations.
Concluding Thoughts
As I think about prevention and intervention in childhood, adolescence and adulthood, I want to return to the integrated framework for understanding gender incongruence. Recall that the framework draws from the following three frameworks or lenses through which we might view gender dysphoria:
The integrity framework, which identifies the phenomenon of gender incongruence as confusing the sacredness of maleness and femaleness and specific resolutions as violations of that integrity.
The disability framework, which identifies gender incongruence as a reflection of a fallen world in which the condition is a disability, a nonmoral reality to be addressed with compassion.
The diversity framework, which highlights transgender issues as reflecting an identity and culture to be celebrated as an expression of diversity.
The integrity framework reminds us why it may be important to at least consider managing a child’s environment in a way that does not reinforce cross-gender behavior and identity. Having worked with parents around the presentation of a child’s cross-gender identity and behavior, redirecting a child’s behaviors and ways of relating is a challenge for parents who may otherwise wish to affirm an integrity framework, as it can be experienced as going against what seems to come almost naturally to the child. This can create ambivalence for parents who also love and want to find practical ways to support their child. These parents might be drawn to more of a watchful waiting approach to what appears to be gender incongruence.
The integrity framework would give the Christian pause when thinking of puberty suppression. That is not to say a Christian parent would not consider such an intervention, but the integrity framework reminds them to think through several issues before making that kind of decision, particularly if suppression was recommended to start at or prior to the time when an older child’s experiences of gender dysphoria could yet desist. That decision could be a remarkably difficult and painful one, and consultation with experts in this area would be important.
The disability framework reminds us to demonstrate great compassion and empathy as we think about a child who is displaying signs of gender dysphoria. It also reminds us to be supportive of parents who may feel quite isolated and ashamed, as though they were concerned that people in their community would think that they caused the gender identity concerns.
Although perhaps not as critical for identity in childhood, the weak form of the diversity framework reminds us of meaning-making structures and how our understanding of gender dysphoria needs to also be affirmative of a young child’s value and dignity. When we fail to provide a sense of meaning and purpose and pathways to identity and community in these other frameworks, we cannot act surprised or offended when people opt for the benefits they find in the diversity framework.
The integrated framework is also critical in adolescence and adulthood. Let me talk about the integrity framework and the disability framework together. The integrity framework gives us pause about the most invasive procedures here. But what does that mean? Many people I have known who experience gender dysphoria have found it helpful, in keeping with a disability framework, to think of ways they can learn to manage their gender dysphoria. Different behaviors or dress may not be ideal, but the person identifies the least invasive way to manage their dysphoria so that it does not become too distressing or impairing. This places such management on a continuum from least to most invasive and recognizes that hormonal treatment and sex reassignment would be the most invasive. This is not to say a Christian would not consider the most invasive procedures; I know many who have. But they would not begin there, nor would they take such a decision lightly. Ideally, they would consider options based upon the input and recommendations from experts in this area, as well as thoughtful and prayerful consideration with a discernment group of those whose perspectives they respect.
The diversity framework raises questions of personal value, worth and dignity. It is particularly important because the disability framework does not do all that much for a sense of identity. Most people do not find, “I’m managing my dysphoria in the least invasive way” as a particularly meaningful storyline for identity and community. Recall that the trends toward transitioning are affirming precisely because they help to answer questions about identity and community in ways that truly resonate with a person’s psychological and emotional experience of their gender identity. Any attempt at intervention in adolescence and adulthood would benefit from reflecting a meaning-making structure that informs identity and locates the person within a broader community of support. This community would function as a kind of kinship network (family) that affirms their worth and insists on navigating this terrain together, even when decisions may be quite complex and challenging to all involved.
6
Toward a Christian Response
At the Level of the Individual
Let me share the story of another person whom I know as Blake, a female-to-male transgender person who was formerly known to others as Brooklyn:
Brooklyn struggled with gender dysphoria from a young age. She was born and raised in a small town in the South, where she was brought up in a fundamentalist church. Her parents took creative steps to present toys and games and attire to match her birth sex as female. They would offer a few toys, and Brooklyn “always” preferred the stereotypically boy games (e.g., action figures, Matchbox cars, toy guns), despite always having at least one option that was more stereotypically for girls (e.g., Barbie, baby dolls). Brooklyn shared how her preferences for cross-sex toys/games/attire kept bumping up against their expectations for gender identity and role. Over the next several years, as Brooklyn’s interests persisted, Brooklyn’s parents struggled with whether her cross-sex-typed interests meant she was going to hell. They saw nothing other than condemnation in her presentation and interests. “They could not see me,” Brooklyn shared with me. As a result, this was a huge fear of hers for many years. Brooklyn struggled in not finding acceptance within her religion, and she struggled with a strong desire to take her life that persisted through college and beyond. During those years, Brooklyn managed her dysphoria initially by presenting as a lesbian and by wearing very masculine attire through college. These experiences were “okay” for a time but ultimately dissatisfying as they did not seem to address the more fundamental concerns.
In one of her darkest moments, it was her grandfather, a fundamentalist Christian and patriarch of the family, who spoke new life into her when he said, “You’ll have to find a path to God that will work for you, and it’s going to be hard. It won’t be the same path I took.” Brooklyn shed tears that had been pent up for years. She had not known that there was still a path to God for her. She would later begin the long process of transitioning. Brooklyn shared with me that the word “transitioning” suggests everyone does all of the same things to present in a cross-sex manner. Not so. As Brooklyn reflected on the meaning of that word, she said, “Each person considers what transitioning is for that person.” For Brooklyn, it has meant some surgery (chest) and some use of hormones but not much more at this time. Brooklyn eventually adopted the name Blake, a favorite name that was associated in his mind with his grandfather. He eventually decided to explore that path to God his grandfather had spoken of and found a church, Bible study and small group that would create room for him to study and pray and share life together. He disclosed to his pastor and was told, “You are welcome here.” He is now beginning to explore a path to God and find a way forward after years of searching.
Blake presents the church with a remarkable challenge. It is hard to know what is best for someone who is navigating gender dysphoria from such a young age and in a way that leads to self-destructive thoughts. A place to begin to is to come to a better understanding of the phenomenon that the person you are talking to experiences. I hope this book has provided information that will help you toward that end. You will learn a lot, too, from listening to the person’s story.
When it comes to meeting with someone who is navigating gender identity concerns, I rely on elements of narrative therapy. Narrative therapy focuses on the role of socially constructed “scripts” in a person’s life. What is perhaps most interesting about narrative approaches to therapy is that they are often used with marginalized groups whose “story” has been written by a dominant culture: “On a larger level, entire groups of people could have their story about themselves completely overtaken by a more dominant group story about them.”1
In their description of narrative therapy, Zimmerman and Dickerson describe the ways in which cultural stories can create narratives that can lead to difficulties for the person:
Cultural stories determine the dimensions that organize people’s experience. These narratives about what is canonical provide a backdrop against which experiences are interpreted. Cultural stories are not neutral. . . . They lead to constructions of a normative view, generally reflecting the dominant culture’s specifications, from which people know themselves and against which people compare themselves.2
Most mainstream, secular narrative approaches to gender dysphoria would posit that it is the sex and gender binary that is oppressive to the person who is gender dysphoric. This is an interesting perspective steeped largely in the strong form of the diversity framework, and it is something that needs to be argued for rather than assumed to be the case.
In any case, I do not use narrative therapy with that set of philosophical assumptions. However, because interpretation is so important in narrative approaches, I do see benefit in some of the techniques that can inform meaning making and decisions about identity and gender. For example, I find it helpful when I first meet with someone who experiences gender dysphoria to map gender identity conflicts in their life, both current conflicts and the person’s history with those conflicts.
Mapping Gender Identity Conflicts
Recall that we do not know what causes these various experiences of gender incongruence. Indeed, the range of presentations should give us pause that any one theory of etiology will suffice. There are likely multiple influences that are weighted differently for different people, and these influences likely contribute to a range of outcomes.
Figure 6.1.
The first consideration in mapping gender identity conflicts raises the question, How does the person experience his or her gender identity concerns? What is it like for this person in particular? Besides asking the person to share more about their experiences, one thing that can be helpful is gauging a person’s experience of gender incongruence, as well as a person’s sense for how they are managing that incongruence.
Although we are focusing here on the experience of gender dysphoria in terms of strength of incongruence and capacity to manage it, keep in mind that the gender identity concerns, while important, may not be the greatest concern in this person’s life. Consider together whether there are other pressing issues to attend to, such as a marriage or relationships with family members or personal walk with God, education, and so on. Too often Christians can focus almost exclusively on the very aspect of the person with which we are most uncomfortable.
In a workbook I recently developed with some colleagues, we offer an opportunity to reflect on these two experiences in a way that recognizes the differences between sense of incongruence and one’s ability to live with that incongruence.3 We invite a person to identify their subjective sense of incongruence as well as their subjective sense of distress. A person can identify ways in which gender dysphoria has influenced him or her, as well as how the person has influenced gender identity concerns. The person can keep a journal and record various experiences over the next couple of weeks in which gender identity concerns are influencing them. A person might write, “I feel preoccupied with these issues every day. It’s hard to focus on other things that are also important to me.” Another person might record the following: “I get discouraged. Sometimes I feel shame, like I am not who I should be.”
