The leading Christian scholar on gender dysphoria defines the terms—and gives the church a way forward.
I still recall one of my first meetings with Sara. Sara is a Christian who was born male and named Sawyer by her parents. As an adult, Sawyer transitioned to female.
Sara would say transitioning—adopting a cross-gender identity—took 25 years. It began with facing the conflict she experienced between her biology and anatomy as male, and her inward experience as female. While still Sawyer, she would grow her hair out, wear light makeup, and dress in feminine attire from time to time. She also met with what seemed like countless mental-health professionals as well as several pastors. For Sawyer, now Sara, transitioning eventually meant using hormones and undergoing sex reassignment surgery.
Sara would say she knew at a young age—around 5—that she was really a girl. Her parents didn’t know what to do. They hoped their son was just different from most other boys. Then they hoped it was a phase Sawyer would get through. Later, two pastors told them that their son’s gender identity conflicts were a sign of willful disobedience. They tried to discipline their son, to no avail.
Sara opened our first meeting by saying, “I may have sinned in the decisions I made; I’m not sure I did the right thing. At the time, I felt excruciating distress. I thought I would take my life. What would you have me do?” The exchange was disarming.
I have worked with people like Sara for more than 16 years. Although most of my published research and clinical practice is in the area of sexual identity, I regularly receive referrals to meet with people who experience conflicts like Sara’s. The research institute I direct, housed at Regent University in Virginia, published the first study of its kind on transgender Christians a few years ago. My experiences counseling children, adolescents, and adults have all compelled me to further study gender dysphoria.
From this research and counseling background, I hope to offer the Christian community a distinctly Christian response to gender dysphoria.
Defining the Terms
First, let’s define our terms. “Gender identity” is simply how people experience themselves as male or female, including how masculine or feminine they feel. “Gender dysphoria” refers to deep and abiding discomfort over the incongruence between one’s biological sex and one’s psychological and emotional experience of gender. Sara would say she lived much of her life as a woman trapped inside a man’s body. When a person reports gender identity concerns that cause significant distress, he or she may meet criteria for a gender dysphoria diagnosis.
The previous version of the American Psychiatric Association’s diagnostic manual included the diagnosis “gender identity disorder.” It highlighted cross-gender identity as the point of concern. The newest version refers instead to “gender dysphoria,” moving the discussion away from identity and toward the experience of distress. A lack of congruence between one’s biological sex and gender identity exists on a continuum, so when diagnosing gender dysphoria, mental-health professionals look at the amount of distress as well as the amount of impairment at work or in social settings.
It is hard to know exactly how many people experience gender dysphoria. Most of the research has been on “transsexuality.” The term refers to a person like Sara who wishes to or has identified with the opposite sex, often through hormonal treatment or surgery. The American Psychiatric Association estimates the number of transsexual adults as low as 0.005 to 0.014 percent of men and 0.002 to 0.003 percent of women. But these are likely underestimates, as they are based on the number of people who visit specialty clinics.
The highest prevalence estimates come from more recent surveys that include “transgender” as an option. “Transgender” is an umbrella term for the many ways people experience a mismatch between their gender identity and their biological sex. So not everyone who is transgender experiences significant gender dysphoria. Some people say their gender resides along a continuum in between male and female or is fluid. They do not tend to report as much distress. Prevalence here has ranged from 1 in 215 to 1 in 300.
This means that transgender people are much more common than those formally diagnosed with gender dysphoria, but not nearly as common as those who identity as gay or lesbian, which is 2 to 4 percent of the US population.
While on the topic of homosexuality, let me clarify that gender dysphoria and transgender issues are not about having sex or attraction to the same sex; they are about an experiential mismatch between one’s psychology and one’s biology. People often confuse the two, likely due to transgender being a part of the larger lesbian, gay, bisexual, and transgender (LGBT) discussion.
Psychologists and researchers don’t know what causes gender dysphoria. The most popular theory among those who publish on this topic is the brain-sex theory. It proposes that the brain maps toward male or female, which in nearly all cases corresponds with various biological indicators of sex: chromosomes, gonads, and sex hormones. In rare instances, the normal sex differentiation that occurs in utero occurs in one direction (differentiating toward male, for example), while the brain maps in the other direction (toward female). Several gaps remain in the research behind this theory, but it nonetheless compels many professionals.
Recently a mother came to me, worried about her 7-year-old son. “What can we do?” she asked. “Just last week a woman at the park said something. I couldn’t believe she had the nerve. I’m afraid the kids at school might do worse.”
The mother noted that her son’s voice inflection seemed more like a girl’s and that he pretended he had long hair. Over the past weekend, he had grabbed a towel and put it around his waist and said, “Look, Mom, I’m wearing a dress just like you!”
Gender dysphoria and transgender issues are not about having sex or attraction to the same sex; they are about an experiential mismatch between one’s psychology and one’s biology.
Whether and how to intervene when a child is acting in ways typical of the opposite sex is a controversial topic, to say the least. It’s important to remember that in about three of four of these cases, the gender identity conflict resolves on its own, lessening or ceasing entirely. However, about three-fourths of children who experience a lessening or resolution go on as adults to identify as gay, lesbian, or bisexual—a fact that psychologists don’t fully understand at this time.
What happens to children when their gender identity conflict continues into adulthood? Psychiatrist Richard Carroll proposes that they face four outcomes: (1) live in accordance with one’s biological sex and gender role; (2) engage in cross-gender behavior intermittently; (3) adopt a cross-gender role through sex reassignment surgery; or (4) unresolved (the clinician has lost contact with the person and doesn’t know what happened).
Sara pursued the third outcome. Bert pursued the second. He’s a biological male who for years has engaged in cross-gender behavior from time to time to “manage” his gender dysphoria. He wears feminine undergarments that no one apart from his wife knows about. He has grown his hair out and may wear light makeup, and this has been enough to manage his dysphoria.
Crystal pursued the first option. She has experienced gender dysphoria since childhood. It has ebbed and flowed throughout her life, but she’s able to cope with it. She presents as a woman and has been married to a man for 12 years. He is aware of her dysphoria.
Few studies have shown that therapy successfully helps an adult with gender dysphoria resolve with their biological sex. This may be one reason professionals generally support some cross-gender identification in therapy.
As someone with gender dysphoria considers different ways to cope, what might the Christian community distinctly offer them?
To answer this question, let me first describe three cultural lenses through which people tend to “see” gender dysphoria.
Lens #1: Integrity. The integrity lens views sex and gender and, therefore, gender identity in terms of what theologian Robert Gagnon refers to as “the sacred integrity of maleness or femaleness stamped on one’s body.” Cross-gender identification is a concern because it threatens to dishonor the creational order of male and female. Specific biblical passages, such as Deuteronomy 22:5 or 23:1, bolster this view. Even if we concede that some of the Old Testament prohibitions were related to avoiding pagan practices, nonetheless, from beginning to end, Scripture reflects the importance of male-female complementarity set forth in creation (Gen. 2:21–24).
The theological foundation of the integrity lens raises the same kind of concerns about cross-gender identification as it raises about homosexuality. Same-sex sexual behavior is sin in part because it doesn’t “merge or join two persons into an integrated sexual whole,” writes Gagnon. “Essential maleness” and “essential femaleness” are not brought together as intended from creation. When extended to transsexuality and cross-gender identification, the theological concerns rest in what Gagnon calls the “denial of the integrity of one’s own sex and an overt attempt at marring the sacred image of maleness or femaleness formed by God.”
The integrity lens most clearly reflects the biblical witness about sex and gender. While it may be challenging to identify a “line” in thought, behavior, and manner that reflects cross-gender identification, people who see through the integrity lens are concerned that cross-gender identification moves against the integrity of one’s biological sex—an essential aspect of personhood.
It should be noted that some Christians do not put gender dysphoria in the same category as homosexuality. They may have reservations about more invasive procedures; however, they do put gender dysphoria or trying to manage dysphoria in the same class of behaviors that Scripture deems immoral.
Lens #2: Disability. This lens views gender dysphoria as a result of living in a fallen world, but not a direct result of moral choice. Whether we accept brain-sex theory or another account of the origins of the phenomenon, if the various aspects of sex and gender are not aligning, then it’s one more human experience that is “not the way it’s supposed to be,” to borrow a phrase from theologian Cornelius Plantinga Jr.
When we care for someone suffering from depression or anxiety, we do not discuss their emotional state as a moral choice. Rather, the person simply contends with a condition that comes in light of the Fall. The person may have choices to make in response to the condition, and those choices have moral and ethical dimensions. But the person is not culpable for having the condition as such. Here, the parallel to people with gender dysphoria should be clear.
Those who use this lens seek to learn as much as they can from two key sources: special revelation (scriptural teachings on sex and gender) and general revelation (research on causes, prevention, and intervention, as well the lives of persons navigating gender dysphoria). This lens leads to the question: How should we respond to a condition with reference to the goodness of Creation, the reality of the Fall, and the hope of restoration?
Those drawn to the disability lens may value the sacredness of male and female differences; this is implied in calling gender dysphoria a disability. But the disability lens also makes room for supportive care and interventions that allow for cross-gender identification in a way the integrity lens does not.
Lens #3: Diversity. This lens sees the reality of transgender persons as something to be celebrated, honored, or revered. Our society is rapidly moving in this direction. Those drawn to this lens cite historical examples in which departures from a clear male-or-female presentation have been held in high esteem, such as the Fa’afafine of Samoan Polynesian culture.
Whereas the biological distinction between male and female is considered unchangeable, some wish to recast sex as just as socially constructed as gender. To evangelicals, those who want to deconstruct sex and gender norms represent a much more radical alternative to either the integrity or disability lens.
To be sure, not everyone drawn to the diversity lens wants to deconstruct sex and gender. What is perhaps most compelling about this lens is that it answers questions about identity—“Who am I?”—and community—“Of which community am I a part?” It answers the desire for persons with gender dysphoria to be accepted and to find purpose in their lives.
A Distinctly Christian Resource
I believe there are strengths in all three lenses. Because I am a psychologist who makes diagnoses and provides treatment to people experiencing gender dysphoria, I see value in a disability lens that sees gender dysphoria as a reflection of a fallen world in which the condition itself is not a moral choice. This helps me see the person facing gender identity confusion with empathy and compassion. I try to help the person manage his or her gender dysphoria.
When I consider how best to counsel my clients to manage their gender dysphoria, I add the caveat: in the least invasive way possible.
Even as Christians affirm the disability lens, we should also let the integrity lens inform our pastoral care. That lens represents a genuine concern for the integrity of sex and gender, and the ways in which maleness and femaleness help us understand the nature of the church and even the gospel.
Yet we should reject the teaching that gender identity conflicts are the result of willful disobedience or sinful choice. The church can be sensitive as questions arise about how best to manage gender dysphoria in light of the integrity lens. And we can recognize that we live in a specific cultural context, and that many gender roles vary from culture to culture. When I consider how best to counsel my clients to manage their gender dysphoria, however, I add the caveat: in the least invasive way possible.
Christians can also acknowledge how the diversity lens affirms the person by providing an identity not addressed by the other two lenses. The diversity lens emphasizes the importance of belonging. We must remember that the transgender and broader LGBT community are attractive because they answer the bedrock question, “Where do I belong?” Most churches want to be a community where people suffering from any “dysphoria” will feel they belong, for the church is, after all, a community of broken people saved by grace.
A few years ago, my research team at the Institute for the Study of Sexual Identity conducted the first study of its kind on transgender Christians. We collected information on 32 biological males who to varying degrees had transitioned to or presented as women. We asked many questions about issues they faced in their home, workplace, and church, such as, “What kind of support would you have liked from the church?” One person answered, “Someone to cry with me rather than just denounce me. Hey, it is scary to see God not rescue someone from cancer or schizophrenia or [gender dysphoria]...but learn to allow your compassion to overcome your fear and repulsion.”
When it comes to support, many evangelical communities may be tempted to respond to transgender persons by shouting “Integrity!” The integrity lens is important, but simply urging persons with gender dysphoria to act in accordance with their biological sex and ignore their extreme discomfort won’t constitute pastoral care or a meaningful cultural witness.
The disability lens may lead us to shout, “Compassion!” and the diversity lens may lead us to shout “Celebrate!” But both of these lenses suggest that the creational goodness of maleness and femaleness can be discarded—or that no meaning is to be found in the marks of our suffering.
Most centrally, the Christian community is a witness to the message of redemption. We are witnesses to redemption through Jesus’ presence in our lives. Redemption is not found by measuring how well a person’s gender identity aligns with their biological sex, but by drawing them to the person and work of Jesus Christ, and to the power of the Holy Spirit to transform us into his image.
Let’s say Sara walks into your church. She looks like a man dressed as a woman. One question she will be asking is, “Am I welcome here?”
As Christians speak to this redemption, we will be tempted to join in the culture wars about sex and gender that fall closely on the heels of the wars about sexual behavior and marriage. But in most cases, the church is called to rise above those wars and present a witness to redemption.
Let’s say Sara walks into your church. She looks like a man dressed as a woman. One question she will be asking is, “Am I welcome here?” In the spirit of a redemptive witness, I hope to communicate to her through my actions: “Yes, you are in the right place. We want you here.”
If I am drawn to a conversation or relationship with her, I hope to approach her not as a project, but as a person seeking real and sustained relationship, which is characterized by empathy as well as encouragement to walk faithfully with Christ. But I should not try to “fix” her, because unless I’m her professional therapist, I’m not privy to the best way to resolve her gender dysphoria. Rather, Christians are to foster the kinds of relationships that will help us know and love and obey Jesus better than we did yesterday. That is redemption.
If Sara shares her name with me, as a clinician and Christian, I use it. I do not use this moment to shout “Integrity!” by using her male name or pronoun, which clearly goes against that person’s wishes. It is an act of respect, even if we disagree, to let the person determine what they want to be called. If we can’t grant them that, it’s going to be next to impossible to establish any sort of relationship with them.
The exception is that, as a counselor, I defer to a parent’s preference for their teenager’s name and gender pronoun. Even here I talk with the parent about the benefits and drawbacks of what they want and what their teenager wants if the goal is to establish a sustained, meaningful relationship with their child.
Also, we can avoid gossip about Sara and her family. Gossip fuels the shame that drives people away from the church; gossip prevents whole families from receiving support.
Chapters in Redemption
In some church structures, the person’s spiritual life is under the care of those tasked with leading a local congregation. In this case, we have to trust church leadership to do the hard work of shepherding everyone who accepts Christ as Lord and Savior. We trust, too, that God is working in the lives of our leaders to guide them in wisdom and discernment. We trust that meaningful conversations are taking place, and we can add our prayers for any follower of Christ.
In other church settings, it might be us as laypeople who are called into a redemptive relationship with the transgender person. After all, Christians are to facilitate communities in which we are all challenged to grow as disciples of Christ. We can be sensitive, though, not to treat as synonymous management of gender dysphoria and faithfulness. Some may live a gender identity that reflects their biological sex, depending on their discomfort. Others may benefit from space to find ways to identify with aspects of the opposite sex, as a way to manage extreme discomfort. And of course, no matter the level of discomfort someone with gender dysphoria experiences (or the degree to which someone identifies with the opposite sex), the church will always encourage a personal relationship with Christ and faithfulness to grow in Christlikeness.
Certainly we can extend to a transgender person the grace and mercy we so readily count on in our own lives. We can remind ourselves that the book of redemption in a person's life has many chapters. You may be witness to an early chapter of this person's life or a later chapter. But Christians believe that God holds that person and each and every chapter in his hands, until that person arrives at their true end—when gender and soul are made well in the presence of God.
Mark Yarhouse is the Rosemarie S. Hughes Endowed Chair and professor of psychology at Regent University, where he directs the Institute for the Study of Sexual Identity. His most recent book is Understanding Gender Dysphoria: Navigating Transgender Issues in a Changing Culture (IVP Academic).