Understanding Gender Dysphoria

Book Review (Mark Yarhouse)

I first heard about Yarhouse and his work on a John Dickson podcast about transgender issues, and he sounded like the kind of person I wanted to read on the issue - someone who seems to sit in a relatively similar theological camp, who spoken sensitively and carefully about these issues, and in fact his professional training and work as a clinical psychologist and researcher deals primarily with the care of those dealing with gender dysphoria.

That's, from the title, the topic of this book - it's an introductory text in which Yarhouse does two main things: (1) provides an introductory explanation of what gender dysphoria is, what we know about it and don't know, and both standard approaches in the field as well as some snippets of people's personal experiences from his research; (2) Yarhouse provides some (by no means comprehensive!) elements towards both a Christian perspective on gender dysphoria, and towards responses both on a personal and an institutional level.

What is gender dysphoria? Yarhouse explains it like this: when one's experience of gender identity (i.e., their psychological, social, cultural, and emotional experience of being male or female), does not align with their birth sex. He does not provide a clear, one-line description of sex, but does define it as primarily a binary assignation "typically with reference to chromosomes, gonads, sex hormones, and internal reproductive anatomy and external genitalia" (p16).

Dysphoria, then, refers to the dis-ease, the discomfort, of an existence in which to a greater or lesser extent one's subjective experience of gender, is at odds with the biological sex that one is born with. Transgender is an umbrella term for how people present/experience/live out that incongruity; transsexual is a term more restricted for those intending, or having, transitioned (to varying degrees) their biological sex to match their experienced gender.

Yarhouse is really good at explaining a whole bunch of complicated things in a way that is simple(r), without you going "oh, that's easy" - you still retain the understanding that it's a lot more complicated than anything that can be fit in an introductory volume of this size, and that you're not an expert. One of his early, and repeated points, is that people do not choose to experience gender dysphoria. Gender dysphoria is something some people experience, and our response to them (whoever we are in relation to them), is to be guided by sensitivity, listening, and providing support for them as they navigate that experience.

Chapter 2 explicitly deals with a Christian perspective, and Yarhouse actually provides and presents three perspectives, which he terms frameworks: Integrity, Disability, Diversity. Before he does that, Yarhouse so so helpfully talks through "the four acts of the biblical drama: creation, the fall, redemption and glorification." (p35) Among the helpful points he makes in here, is this: that while it's right to speak of the world, and ourselves, as being disordered, it is far less correct (or helpful) to focus on the disordering of others as opposed to (and diminishing) our own. Likewise, Yarhouse recognises that some experience their own forms of disordering as parts of who they are, and identity concerns shouldn't be quickly brushed aside or overridden.

The integrity framework is what is most often trotted out in conservative theological circles, in various versions. Yarhouse, I think, tries to present it in its best light and best form - that there is an intrinsic and sacral dimension to binary sex distinction, and this itself is valuable; things that threaten that integrity are viewed with suspicion and concern, which very often becomes rejection and judgment.

The disability framework sees gender dysphoria as more like a condition, similar to a mental health concern, which is a non-moral aspect of reality in which things aren't exactly how they are to be.

The diversity framework "see[s] [transgender issues] as something to be celebrated, honored or revered." (p50) and an "identity and culture to be celebrated as an expression of diversity." (p50)

In terms of the diversity framework, here and elsewhere Yarhouse makes a salient point - most people who experience gender dysphoria, including most people who transition biologically to become transsexual, are not attempting to deconstruct gender/sex as a binary reality. It's precisely because they experience themselves as the other of two, that they transition. The viewpoint that aims to destroy the very categories of sex and gender is a minority voice, a very loud voice at times, but a minority one, and does not speak for a large number of people experiencing gender dysphoria.

For this reason, Yarhouse distinguishes a strong and weak form of this framework. The strong version he identifies as committed to the "the deconstruction of norms related to sex and gender." (p50), e.g. Judith Butler and the like. The weak version he considers those who find answers to two questions in transgender communities, "who am I?" and "of which community am I a part"?" I think there's an incredible value here in the way Yarhouse understands that transgender communities offer compelling answers to those two questions, in a way that traditional Christian communities regularly fail to, especially when they ignore those questions themselves and both fail to understand other frameworks, as well as insisting loudly that the integrity framework is the only way to approach these issues.

Yarhouse himself argues for an integrated framework, that attempts to engage all three of these perspectives, not necessarily in a balanced and equal way, but nonetheless in a sophisticated and engaged way. Again demonstrating his pastoral insight bought at the cost of his own work:

The church should reject as far too reductionist the teaching that gender incongruence is the result of willful disobedience; such an approach avoids the hard places of ministry and shepherding and keeps the person at bay by placing the blame (and heaping greater shame) on the person navigating gender identity concerns. This is not pastoral care. p56

I will treat more briefly the next few chapters. Chapter 3 discusses etiology - what causes gender dysphoria. The short answer is we don't know. There are several theories, some research, no clear answers. Chapter 4 is phenomenology and prevalence.  Because gender identity issues form a continuum, prevalence is hard to judge, because it depends where you draw the line. Yarhouse also talks through the way that gender dysphoria is diagnosed at a 'condition' level, in children, adolescents, and adults. Prevalence estimates vary considerably:

The DSM-5 estimates that between 0.005 percent to 0.014 percent of adult males and 0.002 percent to 0.003 percent of adult females have Gender Dysphoria. (p92)

This based on people seeking specialty clinics.

other studies put the prevalence estimates in ranges from 1 in 10,000 to 1 in 13,000 males and 1 in 20,000 to 1 in 34,000 females. (p92)

between 1 in 215 and 1 in 300 people identified themselves as transgender in two probability samples. (p93)

It is more commonly experienced by males than females, at a ratio of 3:1 or up to 5:1

Chapter 5 talks through prevention and treatment,  in childhood, adolescence, and adulthood, with a range of options; this is helpful in outlining just how broadly gender dysphoria is dealt with, and that it's not simply "pipeline to medical transition"

Chapters 6 and 7 deal with a Christian response, at an individual and institutional level. In the former, Yarhouse talks through some of his own approaches, but also gives considerable advice about how to approach this issue with an individual. High on his concern here is listening to them, giving them the space, tools, freedom, and security to articulate how they are experiencing this. He also talks carefully through the idea of cultural scripts, and how the transgender community supplies certain scripts - that gender dysphoria is naturally occurring, is more about who you are than how you are, makes you part of the transgender community, and is a core part of your identity. These are powerful narratives, and because they are meaning-making, they are persuasive ones. In contrast, Yarhouse outlines the types of scripts that people with gender dysphoria often hear from christian communities - that this is a sinful, that failing to find worth and purpose in traditional gender roles is willful disobedience, that any and all cross-gender behaviour undermines truth.

We can easily see how and why people experiencing gender dysphoria are hurt by Christians and driven away by that experience, and correspondingly embraced by the transgender community. Yarhouse suggests that other scripts are possible that do not have to surrender Christian faith, but can explore more appropriately the experience of gender dysphoria. He also talks through important issues related to disclosure, communication, and faith-experience.

Institutional responses are those most likely to grab the news headlines, and usually in a negative way. Christian institutions, based on my observation, fare poorly for two reasons: (1) they are often not very good nor very informed in navigating this terrain, (2) they are clear targets for ideologues and ideological reporting. That combination never turns out well. Yarhouse acknowledges that there are no easy solutions here, and in fact no solution is going to please all stakeholders. What he does offer is a set of tools for thinking through responses at this level. In particular - how do we relate the ordering and priority of behave/believe/belong in a Christian community. which comes first? which holds priority? What would it mean to be missional towards transgender individuals and communities? How do we respond with compassion and care to individuals with gender dysphoria. What are the terms of inclusion for our groups? What sort of communities ought we be?

Yarhouse has written an excellent book. It's clear, informed, pastorally sensitive, slow to jump to conclusions, clear about what's unknown, and challenging to the default positions of the culture wars. It doesn't capitulate on biblical truths, but recognises that citing two verses about gender doesn't truly solve things. Yarhouse also has the humility, and the wisdom, to warn readers not to think that having read this book, suddenly they are experts equipped to counsel someone through all the issues of gender dysphoria. But anyone who reads this will come away better equipped to understand some of those issues, and I think that's a start worth having.

I'm going to end with a slight but not very personal reflection. I do know trans people, but I do not know what it's like to experience gender dysphoria to any degree. But I think we who do not, should just take a moment to imagine - imagine for a moment what it would be like to feel like you are not the same gender, or do not match the gender expectations, for the biological sex your body appears to be. That, in and of itself, is going to be a difficult, a psychologically and socially painful, disorienting, testing experience of life to be in, to live in. And then, what will it mean to tell other people that? Especially in a community where the standard discourse is that you have willfully and disobediently chosen to feel like that and you're existence is itself a moral transgression. We can do better than that, in fact we must.