Understanding Gender Dysphoria, page 7
This person is a good example of a Christian who would not likely on her own feel the need to identify as either male or female in terms of a gender binary. She does not reduce her sense of self, her gender roles or her gender attributes into clear-cut distinctions between male/female, between masculine/feminine. She would likely relate to others out of sanctioned categories for ease of presentation and communication but, on her own, she would likely think of herself as a person who has multiple, diverse, and complementary qualities of self/identity, role and attributes.
We will discuss the practical applications of the integrated framework later in the book. It will have to be fleshed out so we have a better sense for what it looks like to take the best qualities of each framework and apply them to a counseling or ministry setting or in the context of a small group or friendship.
Concluding Thoughts
As we saw in chapter one, we recognize that discussions of sex refer to the biological components of chromosomes, gonads, sexual anatomy and secondary sex characteristics. Discussions of gender refer to psychological and cultural components, such as gender identity (the subjective sense of being a male or female and how masculine or feminine a person feels), sexual orientation (toward the same or opposite sex or both), and gender role (adoptions of cultural scripts for maleness or femaleness).63 Given so many different aspects of sex and gender “it is perhaps remarkable that so many align consistently on all seven factors, thus experiencing the full, uncomplicated measure of being a woman or a man.”64
At the same time, people do experience deviations from each one of these areas as reflected in any number of experiences or conditions. One of those people I know personally is Ella. I met Ella when she was sixteen years old. She is a biological female. She looks athletic and was involved in several sports at her high school in a small, rural town in South Carolina. She and her parents came for an extended consultation. All identified themselves as Christians. As a family, they were longtime members of a local church. Ella’s mother was a hairstylist and exuded warmth and Southern charm. Ella’s father was reserved and polite. Both expressed dismay at their daughter’s claim that she was born the wrong sex. They did not know what to make of her statements that she was a boy. In a private meeting with Ella, I was talking to her about theories about the etiology of gender incongruence. At one point I shared, “I don’t think you chose to experience your gender incongruence. It sounds like you ‘found yourself’ with these experiences of incongruence at a fairly young age, and that your experience of dysphoria has increased in recent years.” She was stunned. I asked her about her blank expression. Ella shared, “My mom and dad have taken me to three pastors: our pastor and two other pastors he asked us to talk to. All of them said that I chose this—that I was sinning. All three said that this gender thing was a sign of my disobedience. You are the first person I’ve talked to who said I didn’t choose to feel this way.”
How do we take our theological understanding and apply it to pastoral care, ministry and/or the provision of services to someone like Ella? How are we to understand her gender incongruence? I think a more accurate theological consideration is that her incongruence is one particularly complex expression of the fallen world in which we all live. The creation story points to an experience of alignment between sex and gender that she does not experience—and may not experience this side of heaven. That alignment I am referring to would not be a fixed and rigid stereotype that few could live into, but I tend to think of that alignment as quite broad and flexible with significant diversity that the world has seen within any number of cultural contexts and varied definitions for gender roles and expression.
It is hard to fully understand the nature of the fall and how it has affected Ella. It has been suggested that there are separate dimensions of sexuality, such as the physical anatomy, hormones/endocrine system, social role, sexuality and gender identity.65 We may have to discuss Ella’s gender incongruence with some humility about how the fall has touched some of these dimensions, as well as what it means for her to respond to gender incongruence in a way that decreases her dysphoria. Further, we will have to think about how the church will be a redemptive community and resource to her.
As we think together about redemptive themes for Ella, should one of these dimensions of sexuality and gender be considered more “important” or weighted more in our discussions about gender dysphoria? Those who struggle the most to understand the strong psychological sense of being the opposite sex often give more weight to what seems to be happening deep within their mind than to other facets of sexuality and gender.
Also, our understanding of redemption is very much tied to our understanding of the fall. What we do not want to do is suggest that because experiences of gender dysphoria are not as God intended from creation that Ella has a forced choice between celebrating a diversity paradigm at the expense of the integrity of creation (the integrity framework) or embrace the integrity paradigm at the risk of gender diversity being rendered meaningless—as merely an unfortunate form of suffering that will ultimately be erased in eternity. A third way is to name meaning and purpose in all of our reality (including suffering) that is in need of redemption.
What is true about the integrity paradigm and what is true about the diversity paradigm is brought together for the Christian in the redemption of Christ. Identity is found in brokenness, as a friend of mine who has experienced, and continues to experience, gender dysphoria has shared:
Suffering in Christianity is not only not meaningless, it is ultimately one of the most powerful media for the transmission of meaning. We can stand in adoration between the cross, and kneel and kiss the wood that bore the body of our Saviour, because this is the means by which the ugly meaningless atheistic suffering of the world (the problem of evil) was transmuted into the living water, the blood of Christ, the wellspring of Creation. The great paradox here is that the Tree of Death and Suffering is the Tree of Life. This central paradox in Christianity allows us to love our own brokenness precisely because it is through that brokenness that we image the broken body of our God—and the highest expression of divine love. That God in some sense wills it to be so seems evident in Gethsemane: Christ prays “Not my will, but thine be done,” and when God’s will is done it involves the scourge and the nails. It’s also always struck me as particularly fitting and beautiful that when Christ is resurrected His body is not returned to a state of perfection, as the body of Adam in Eden, but rather it still bears the marks of His suffering and death—and indeed that it is precisely through these marks that He is known by Thomas.66
Ella’s experience of gender dysphoria is a reflection of things not being as they were originally intended to be but also not a surprise to God in terms of God’s omniscience and sovereignty. Is it too much to say that it is in this context of suffering that both meaning and identity are found? As we think about how redemptive themes are being written in and through each of our lives, we have to demonstrate great pastoral sensitivity in these encounters. Also, to become a redemptive community, the local church will have to be a place of grace and maturity.
As Jones observes, “Resolution of . . . discord may take many forms, and require us as humble stewards to make complex choices.”67 After we look in the next couple of chapters at what we know and do not know about causes and the possibility of prevention and/or resolution, we will consider what it means to be humble stewards, as well as what it looks like to be the church in any meaningful sense to fellow Christians who are navigating this terrain.
3
What Causes Gender Dysphoria?
“I don’t think you chose to experience gender dysphoria,” I offered slowly, looking at Jeremy who had been looking away ever since he explained how long he had felt different from other boys he knew. He hadn’t held eye contact once since he began talking about the time his mother caught him dressing in his sister’s clothing one day after school. He wouldn’t look at me when he shared how his father confronted him that same night when he came home from work. After I spoke, he turned toward me to catch my eye, as if he wanted to confirm I wasn’t just saying this to make him feel better. You see, he had been told by other Christians just the opposite—that he had indeed chosen to feel like a girl; that his experience of gender dysphoria was an act of willful disobedience to be confronted by his parents if they hoped to help him, if they hoped to save him.
When you think about it, there is something rather remarkable in the claim that an adolescent would choose gender dysphoria to make life difficult for his parents or to essentially thumb his nose at God and at creation. It must seem like a more manageable conclusion to draw than taking the time to explore the questions of etiology in any depth. While a young person could experience questions about gender identity along a continuum, and I am sure some could play out family dynamics and drama through being nonconforming in many aspects of their lives, that is not the same thing as saying a person chooses gender dysphoria.
The most concise answer to the question of causation is this: we do not know what causes gender dysphoria. The reality is that while there are several theories for the etiology of gender dysphoria, the cause(s) is still unknown.
As we begin to look at the question of gender dysphoria, we also have to consider: what is the nature of the dysphoria? Is it the subjective sense of gender incongruence in and of itself, or is it the subjective sense of negative affect in light of the gender incongruence? The recent entry in the DSM-5 was intended to essentially de-pathologize the gender incongruence that is the hallmark of gender identity concerns and focus on the dysphoria itself, which is the subjective distress sometimes associated with that incongruence and the desire to live as the other sex. In this nomenclature, if that dysphoria causes clinically significant distress or impairment, a person might be diagnosed with Gender Dysphoria.
But we also see in the DSM-5 a concerted effort to shift the focus away from biological sex to assigned gender. For example, as we look at the diagnosis of Gender Dysphoria in childhood, one of the symptoms reads,
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.1
A concern raised by some critics2 is that the language change seems to be more about an intersex3 condition in which the language of “assigned gender” is significant because the hallmark of an intersex condition is that it is difficult to identify a child’s sex at birth by looking at that child’s external genitalia. But to refer to assigned gender when there is no evidence that the sex of the child is anything other than what is reflected in the child’s external genitalia seems out of place to critics and lends itself to contrasting socially constructed gender with the essentialism of biological sex.4
To return to the question of gender dysphoria, we have to at least ask if the phenomenon of gender incongruence itself is the concern and not only the emotional reaction to the gender incongruence.5 In his prior work discussing gender dysphoric children and adolescents, Zucker6 observes that the trajectory a child or adolescent is on constitutes a kind of impairment insofar as we can identify the end state toward which the person is moving (that is, a strong desire for hormonal treatment and sex-reassignment surgery).
Another way to look at gender dysphoria is to consider whether cross-identification is a reflection of distress in and of itself. Could it be argued, as Zucker does, that the commitment to cross-gender identification, expression and role are evidence of a conflict between one’s biological sex (“somatic sex”) and psychological and emotional experience of gender identity (“psychological gender”)?7 Does it matter how distressing this state is? Of course. But do we want to say that if there is no subject distress or impairment in social or occupational functioning that the incongruence is itself not a concern? I think we would have a range of answers to that question, certainly among mental health professionals and also among those who are a part of the transgender community, as well as those in religious/faith communities.
Why is this important? It is important in terms of identifying whether we have a broad cultural and professional consensus on this topic. It’s not clear that we do. There are genuine disagreements among professionals about how best to conceptualize this issue, and these differences will also likely be evidenced within our broader culture and within the church.
In addition, as Christians reflect on the topic of gender dysphoria, we bring a worldview that sees a connection between the world we know and experience and transcendent purposes from creation, in the context of the fall, and through redemption and glorification. Even if the profession and the culture move toward seeing transgender issues as completely healthy and hormonal treatment and sex-reassignment surgery as preferred treatment interventions, Christians might still be concerned about that response for those who might be encourage to pursue that outcome.
Heterogeneity Under the Umbrella of Being Transgender
As we consider etiology, we have to recognize that insofar as we are discussing transgender issues as a group of like concerns, we quickly realize that there is great heterogeneity among these different phenomena. While the focus of this book is primarily on gender dysphoria or the phenomenon in which “one’s internal sense of gender does not match one’s genetic gender, body, or gender role,”8 there is a range of persons who may identify as transgender, as Richard Carroll observes:
The clinician is now confronted with an often-bewildering array of individuals with transgender experiences, including transsexuals, transvestites, she-males, queers, third sex, two-spirit, drag queens, drag kings, and cross-dressers. The phrase “transgender experience” is currently used to refer to the many different ways individuals may experience a gender identity outside of the simple categories of male or female. It should be remembered that there are many individuals who have blended genders in some way, who never seek treatment, and who may be very comfortable with their atypical gender identity.9
I would add to this that these are very different experiences, presentations and motivations. There is cross-dressing behavior in and of itself. Different people cross-dress for different reasons. Some cross-dress to manage dysphoria, others to express themselves. Still others cross-dress for sexual arousal.10 Not all of these individuals experience gender dysphoria, nor would all identify as transgender necessarily. In addition to motivation, there is the male-to-female experience of gender incongruence, which can take different forms or expressions and may well have different causal pathways. There is the female-to-male experience of gender incongruence. There are biological males and females who cross-dress privately or publicly (cross-dressers), and there are biological males who cross-dress publicly for shows (drag queens) and biological females who cross-dress publicly for entertainment (drag kings).11
Ted is a thirty-nine-year-old biological male who has been growing out his hair and wearing light makeup for the past eighteen years. He finds that these rather simple steps help him manage his experience of gender dysphoria. He says he doesn’t mind that people relate to him as male despite thinking of himself as essentially more genderfluid than anything else.
Sherrie is a thirty-year-old biological female who has been cross-dressing for four years. She likes to dress in masculine, or at least androgynous, attire, and is told by others that she has a more masculine appearance and plays into various male stereotypes. She says she is most comfortable in this presentation.
Bev is a seventeen-year-old biological female who has experienced gender incongruence for as long as she can remember. She has always been more interested in things the boys did growing up, and she has had no interest whatsoever in playing with girls. She enjoys rough-and-tumble play and identifies with many interests of the boys around her. She believes God made a mistake. She says she is a boy.
Mike is a fifty-six-year-old biological male who has been married for thirty-three years. He and his wife have two grown children together. He believes himself to be neither male nor female. He tends not to use a gender pronoun in describing himself to others; certainly not in how he thinks of himself. He and his wife love each other and are committed to staying together, as difficult and challenging as this experience has been.
Tom is a forty-four-year-old biological male who recently completed a transition with the aid of his therapist, hormonal treatment and sex-reassignment surgery. He uses the name Terrie, which he has always seen himself to be. He was married for twenty years, but he and his wife were unable to continue on after he finalized his plan to transition. Although she loves her husband, she has said she cannot be in what amounts to a same-gender relationship.
There is also no guarantee that each of these has its own specific cause. It very well may be that there are multiple pathways to the same endpoint (equifinality). In the case of transgender issues, the one endpoint is like saying I am going to visit the East Coast. Not only are there many ways to get to the East Coast, there are many ways to be at the East Coast (think about states that have an eastern shore, such as Virginia, Delaware, South Carolina, Florida, and countless cities that are along the coast). That is probably a better conceptual frame of reference for a discussion of both causation and destination when we think of cross-dressing, gender-bending, male-to-female transgenderism, female-to-male transgenderism, and so on.
