Pastoral Paper

WRITTEN BY: MARK A. YARHOUSE, PSY.D. JULIA SADUSKY, M.A.

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A CHRISTIAN SURVEY OF REASSIGNMENT AND HORMONE THERAPY

WWW.CENTERFORFAITH.COM THE CENTER FOR FAITH, SEXUALITY &

TABLE OF CONTENTS

Introduction PG. 1

What are Hormone Therapy and ? PG. 2

The Efectiveness of Hormonal Therapy and Sex Reassignment PG. 4

What about ? PG. 7

Trends among Younger Teens PG. 9

Alternative Ways to Manage Distress PG. 11

Pastoral Recommendations PG. 13

Notes PG. 16

About the Authors PG. 18 PASTORAL PAPER 10

Introduction

How should Christians respond to sex reassignment surgery and hormone therapy? There is no shortage of people weighing in on this question. Far too often, however, the answers we give (or the answers we choose to believe) are based more on assumptions and caricatures than they are on thoughtful investigation of the questions under discussion. Until Christians have taken the time to grapple with the complexities of questions and their physical and psychological implications, our biblical and pastoral responses are doomed to fall short of the wisdom, clarity, and compassion we seek.

This paper ofers an introductory survey of psychological research on sex reassignment surgery and hormone therapy, as well as other approaches to managing gender identity conflict. Our focus here is not on expounding biblical approaches to sex and gender; rather, we want to provide accessible psychological data that will equip Christian leaders to respond to gender identity questions with wisdom, clarity, and compassion. We close by making some pastoral recommendations about what this research might mean for those of us seeking to respond with Christ-like love to and gender dysphoric individuals.

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What are Hormone Therapy and Sex Reassignment Surgery?

Hormone Therapy (HT), also called cross-sex typically produced by biological females—as well hormone therapy or hormone replacement as to block the production of therapy, is the name for a medical intervention in testosterone. which a person takes the hormones associated with the other sex. Most often, the goal of HT is Sex Reassignment Surgery (SRS) is also called to support or facilitate a cross-gender identity for Gender Reassignment Surgery, Gender people diagnosed with —that is, Afrmative Surgery, or a number of other names. distress associated with a lack of congruence (Casually, it’s often called a “.”) It refers between their experience of their gender identity not to any one surgery but to a number of and their biological sex. It’s important to that a person who adopts a distinguish HT from the use of hormone blockers cross-gender identity or other-gender identity at the onset of puberty. These are two separate might consider. interventions. The use of blockers can be a way of “buying time” before puberty begins. A young Some of the more common surgeries for a person just entering puberty (at what is called the biological female adopting a cross-gender “Tanner 2” stage of development or the initial identity or other-gender identity focus on onset of puberty) is provided blockers that keep removal of anatomy that is experienced as them from experiencing the physical changes distressing to the person, as when a biological associated with puberty. Puberty can thus be female undergoes chest reconstruction. In this delayed for one or two years so that the older surgery, female breast tissue is reconstructed to child, now a teenager, can make a decision about develop a male chest. Similarly, a biological which direction they want to go in terms of female may undergo a in which the gender identity. uterus is removed. refers to the removal and/or closure of the . HT itself, then, refers to the use of cross-sex Salpingo-oopherectomy refers to the removal of hormones by those who want to adopt a one or both and fallopian tubes. cross-gender identity or otherwise manage their symptoms of gender dysphoria. For a biological A biological female who adopts a cross-gender female, cross-sex hormone therapy entails the identity may also consider interventions such as use of testosterone and is most commonly done metaoidioplasty, the partial cutting loose of the by injection or through implants or patches (now enlarged from the use of HT) so that placed on the skin. Biological males who use it functions more like a penis. Others might cross-sex hormones to facilitate a cross-gender consider a more invasive procedure, , identity or to manage gender dysphoria typically which is the use of skin grafts to construct/attach take estrogens and progestogens—hormones a penis.

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Biological males who adopt a cross-gender identity or other-gender identity will often undergo electrolysis or laser hair removal for facial hair. Some may consider or the use of breast implants to enhance the results that have already begun to occur with HT. Still others may consider removal of the penis () and removal of the testicles (). Some may also undergo , a surgery in which the penis is essentially inverted and shaped into a neo-vagina.

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The Efectiveness of Hormonal Therapy and Sex Reassignment

Do medical and/or surgical interventions relieve single point in time instead of collecting the distress of someone diagnosed with gender longitudinal data. This limits the robustness of the dysphoria?1 Though many people answer this findings from this research.2 Another challenge question using only anecdotal evidence, this with the data is that many of the earlier studies paper surveys the available research to discuss involved research subjects who also had what we know (and what we don’t know) about undergone sex reassignment surgeries. This these strategies to cope with gender dysphoria. makes it difcult to determine the precise impact of HT for those who do not also undergo SRS. There are a number of limitations to existing studies on the psychological efects of HT and The more recent research in this area ofers SRS. First of all, most available studies do not insight into people’s satisfaction with HT compare those who receive hormonal treatment interventions, their quality of life following those or pursue surgery to control groups—that is, interventions, and their levels of psychological groups of people who have similar psychological distress and morbidity. These last variables are experiences but do not undergo those particularly important because those who treatments. Further, all the available studies are experience gender dysphoria are at increased risk observational in nature. The samples tend to be for psychopathology, report significant levels of convenience samples and small in size, which distress, and are at increased risk for suicide, all of limits our ability to generalize the findings. Of the which are often motivators for pursuing medical studies which are labeled longitudinal—that is, interventions.3 Many of the clients we work with studies taking place over an extended period of are cautious when considering steps to manage time—the participants were followed for, in most dysphoria, particularly because they do not want cases, only one year. This underscores our their symptoms of gender dysphoria or any current lack of understanding of the long-term co-occurring symptoms to worsen. It’s important impacts of hormonal treatment and sex for people to understand the likely impact of reassignment surgery. hormonal treatment as they make informed decisions about managing gender dysphoria. First, let’s review research on hormonal treatment outcomes. What is the efect of HT, both Several short-term longitudinal studies have short-term and long-term, on people’s compared psychological distress among psychological and physical health and on their individuals before and after hormonal overall quality of life? Published studies to date intervention. (The word “transsexual” is reserved have not been evaluated through controlled for people who have adopted or plan to adopt a clinical trials, and most of the research is cross-gender identity through medical cross-sectional in nature—that is, it focuses on a interventions.) A retrospective study of 84

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patients found that the number of attempted first year of hormonal treatment.9 While some suicides following the start of hormonal treatment patients may experience complications or dropped from 10 to 4 after patients received their side-efects from using cross-sex hormones, even first dose of hormonal treatment.4 The study doesn’t these complications do not lead most people to help us determine whether continued hormonal stop treatment prematurely.10 Among the possible treatment would continue to have that efect on the side efects is the risk of sterility. Few studies have number of suicide attempts. However, it supports weighed the risks associated with various treatment the expectation that many patients’ distress options (or no treatment) for people with gender decreases when they receive hormonal treatment. dysphoria who want to remain fertile, and this The patients in another study showed statistically would bring up additional moral concerns for some significant decreases in scores on measures of Christians. anxiety, depression, psychological symptoms, and functional impairment after one year of hormonal Meanwhile, what does the research tell us about sex treatment.5 Since anxiety and depression are the reassignment surgeries? The majority of those who most common symptoms facing those who pursue undergo them report being satisfied with the HT interventions,6 these findings are highly decision.11 Several studies report that, after significant to the conversation about managing short-term follow-up, people who experienced gender dysphoria. gender dysphoria felt SRS was a helpful intervention, they rarely doubted their decision, and Some clients may be better or worse candidates for they found that consistent use of hormones and hormonal therapy based on their level of positive surgical outcomes led to higher functioning in other areas of life. One study satisfaction.12 Although dissatisfaction is rare, those suggests that people whose mental health is poorer who are dissatisfied with SRS may experience before they transition are likely to have continued physical complications following the treatment, psychopathological symptoms after transition and greater levels of stress, lack of adequate support and to demonstrate poorer outcomes than those who information throughout the process, or don’t have mental health concerns before disappointment in functional or physical results. transition.7 This research highlights the importance Even in those studies where a small number of of continual care for those who pursue HT, since people described some degree of dissatisfaction, treatment doesn’t necessarily improve all other most people reported improvements in quality of aspects of functioning. life and overall satisfaction with their choice.13

How do people perceive their quality of life after In considering what these studies mean and what receiving HT? In one review of 28 studies, 80% of conclusions we should draw from them, it’s those who received hormones reported important to keep a few things in mind. First, many improvement in gender dysphoria, although the of the studies rely on their subjects’ self-reports of evidence is “of very low quality” due to the design satisfaction, and self-reports are not necessarily the problems mentioned above.8 One study has found most reliable measures of a person’s wellbeing. that most people, particularly biological males who Second, the people who participated in these identify as female (or male-to-female; MtF) subjects, studies of SRS did so because their mental health rank their overall quality of life, body image, and professionals had decided that they were good quality of sexual life significantly higher after the candidates for SRS. If their caregivers had

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concluded that SRS was not “medically necessary” psychiatric hospitalizations” in those who had or would not be a good fit for a candidate, they undergone SRS compared to a control group.16 would have directed that person to alternative and Another study of 104 individuals indicated that less invasive procedures. In other words, those who suicide, if it occurred, was a risk later (in this study experienced positive results did so because a mental 10+ years after transition), and may not have been health professional had already predicted that they related to sex reassignment surgery.17 In any case, were likely to experience positive results. Recently, longer-term follow-up appears to provide a more however, there has been increasing societal accurate and comprehensive picture of wellbeing. pressure to remove mental health professionals At this point, it seems that surgical interventions, from the role of determining whether or not while helpful in addressing gender-related distress, treatment is appropriate. Instead, we are shifting may not be sufcient over time in improving other towards an “” model of care which aspects of functioning. Still, we need more research leaves the decision of whether or not to pursue SRS to inform this entire area of discussion. up to the candidate’s preference. Candidates are told the risks of SRS, but there are fewer perceived A Christian pastor or counselor should consider the barriers to services, even if a mental health pros and cons of the perceived efectiveness of professional has concerns about their efectiveness. SRS/HT. However, they should also integrate this We anticipate that such a shift, if it continues, could psychological data into a more holistic Christian lead to an increase in regret for more invasive vision for gender identity/expression and human procedures. flourishing. Theology and ethics, in other words, must inform pastoral guidance for gender dysphoric What else does the data say about those who have persons. undergone SRS? Research on the level of psychological distress and morbidity rates for transsexual persons is somewhat mixed. In one study of 207 individuals who pursued hormonal and surgical treatment between 1991 and 2009, 86% reported good physical or mental health post-surgery and the mortality rate was 1.5%.14 But not every study agrees. Dhejne et al. was the first study to utilize a nationwide population-based sample, with a control group, and with longer-term follow-up than any previous research, making it a significant contributor to our understanding of the long-term outcomes of those who have undergone sex-reassignment surgeries.15 While earlier research pointed to the significant improvements in wellbeing as a result of transitioning, this study raised concerns about continued difculties post-transition. It revealed “substantially higher rates of overall mortality, death from cardiovascular disease and suicide, suicide attempts, and

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What about Detransition?

There is remarkably little research on the We have already reviewed some of the more experiences of people who detransition—that is, well-known studies, all of which seem to indicate people who did adopt a cross-gender identity that rates of regret and/or subsequent through medical intervention but then crossed detransition have historically been low. There is back to a gender identity in keeping with their little research evidence of detransitioning as a biological sex. Much of what we know is from common or likely outcome for those who have anecdotal accounts. Some people have decided pursued a cross-gender identity. This is not to to detransition as they experienced a shift in their invalidate the case examples which do exist, or to gender identity; others felt regret or otherwise address the questions Christian individuals might reported a sense of conviction that they ought to have about the morality of these interventions, detransition. However, it is impossible to pin but it does caution us from overstating the down exactly how many people have likelihood of regret, at least based on the research de-transitioned. available right now. There is some concern that a lack of willingness to invest in research in this A related question is whether people frequently area, in light of ideological and political regret transitioning, regardless of whether they movement towards encouraging the pursuit of a choose to detransition. This is an important cross-sex identity, could make it difcult for question for those deciding how to cope with researchers to acquire data.18 gender dysphoria, since they don’t want to make a partially or totally irreversible decision if they’re At the same time, it is worth considering what we likely to regret it later in life. There are certainly know about the detransition community. Several reports of regret and decisions to detransition. In blogs and other online resources have put forth some cases, these detransitions are only social; at survey data that is worth attending to, although other times, people have pursued medical and/or none of the surveys posted are peer-reviewed surgical interventions to return to a presentation research studies. In August of 2016 one such in keeping with their biological sex. The survey was posted on multiple social media commonly cited examples of detransition are sources.19 The criteria for participation was that case studies, which means they have limited participants formerly self-described as weight when compared to the population-based transgender and were born as a biological female. studies presented above. Further, the decision to Over two hundred participants (203, to be detransition may not be due to a single reason, precise) were included in the survey. The most such as “regret” for the transition. Medical common reason these participants gave for complications, financial challenges of sustaining detransitioning was political/ideological beliefs hormonal therapies, or other practical reasons (62.9%), followed by finding alternative ways to might also factor into a decision to detransition, cope with dysphoria (59.4%). Other available and these reasons may not negate the reasons a surveys have explored the co-occurring concerns person chose to transition in the first place. of females who detransition20 and the

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management strategies of those who experience gender dysphoria.21 Of the strategies that were helpful for alleviating gender-related distress, the most commonly cited strategies were processing internalized misogyny (82.17%), gaining new perspectives on sex and gender (79.11%), and processing internalized self-hatred (66.85%).

Much more research is needed to better understand the experiences of those who do and do not pursue a transition, and those who detransition, as well as the challenges faced by each group. We are aware of researchers who are currently conducting research on the experiences and decision-making of those who report detransitioning. One surgeon with over twenty years of experiences doing reconstructive surgery indicates that he has seen significant numbers of regret and subsequent requests to detransition, particularly from younger women.22 We anticipate that we will have more research available to us in the coming years. The implications of these findings are important, especially as recent trends increasingly regard social, medical, and surgical transitions as the obvious curative path for those with gender dysphoria.

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Trends among Younger Teens

Historically, gender dysphoria in childhood and words, rather than adopting a cross-gender adolescence was more common in natal males. In identity, as happens when a biological male childhood, natal males were between four and identifies as female, we are seeing an increase in five times more likely to experience gender younger teens identifying as genderfluid, dysphoria than natal females.23 Trends today in genderqueer, agender, gender expansive, and so childhood are similar; natal males are still more on. These are non-binary gender identities. It is likely to experience gender dysphoria. However, possible that some of these adolescents may also in adolescence, we are seeing an increase in natal meet criteria for gender dysphoria, but if so, their females who identify as transgender, and natal dysphoria is developing both later in life (“late females are presenting with late onset gender onset”) and more quickly (“rapid onset”) than dysphoria at higher rates than natal males. most cases of gender dysphoria historically have.26 In addition to a higher proportion of natal females experiencing gender dysphoria or identifying as Gender identity is a trending topic today; in fact, transgender (with an atypical, late-onset the phenomenon has become known as “trans presentation), there has also been an increase in trending.” While some of this discourse is rooted gender identity concerns among those on the in experiences of gender dysphoria, “trans autism spectrum and those who experience trending” appears far more ubiquitous than severe psychopathology. Thus, what once gender dysphoria has historically been. The term seemed like the “typical” experience of people “transgender” is an umbrella term for the many referred to gender identity services is no longer ways people express gender identity when their so typical, and people’s narratives diverge more gender identity does not align with their widely than ever.24 Descriptive studies indicate biological sex as male or female. While some that 87% of applicants at Finland clinics were people who identify as transgender also female, 62% reported conscious questioning of experience distress over this lack of alignment gender beginning after age 12, and 64% did not between their identity and their biological recall gender atypicality or gender dysphoria sex—that is, they experience gender being present in childhood.25 These shifts are dysphoria—others do not. intriguing to the mental health and broader medical community, raising questions about We are concerned that “transgender” as an whether our past and current approaches to umbrella term is becoming home to many other treating gender dysphoria will adequately meet identity questions that naturally arise in the needs of the individuals who more frequently adolescence. As these questions are being seek out gender identity services today. explored by younger teens, some of them may request serious medical interventions. This is in We also see a growing number of younger teens part why we see a growing number of emerging who adopt a non-binary gender identity. In other gender identities such as bigender, genderfluid,

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and gender expansive. identities (for example, gender expansive) as “ways of being” gendered in our present culture. As Christians who are also psychologists, we have found it helpful to distinguish “trans trending” In addition to these concerns, several practical identity and relationship issues from the concerns arise when a young teen transitions. If a psychological or mental health concerns of young teen has yet to go through puberty or has gender dysphoria. It would be important to tease delayed or blocked puberty at the Tanner 2 stage these out, since transitioning has been helpful for (just as puberty changes are beginning to occur), those with gender dysphoria, but may lead to then the teen may not have had an opportunity to more difculties if it is utilized by those who are fully explore his or her natal sex. However, as high exploring identity rather than seeking to manage as 75% to 80% (or more) of children who distress. However, at a practical level, making experience gender dysphoria find that this these distinctions can be remarkably difcult. dysphoria eventually resolves on its own; and What we have referred to as trans trending might older teens whose gender dysphoria has resolved best be described as tied to the “looping efect” on its own often report that the experience of among mental health issues first raised by Ian puberty helped them consolidate their gender Hacking,27 and the experience of genuine identity in keeping with their biological sex. They incongruence between one’s gender identity and may have feared going through puberty, but biological sex which is captured in the diagnosis when their body “voted” in the direction that of gender dysphoria. corresponded with their chromosomes, their gender identity concerns were able to resolve. In The looping efect refers to what happens over other words, young teens who choose to time as the mental health industry categorizes transition before experiencing puberty may lose people, who then respond to their own the opportunity for their gender dysphoria to be categorization, and as professionals interact with naturally resolved during puberty. various stakeholders. These recursive interactions may bring into existence new ways people Unfortunately, for teens whose gender dysphoria experience themselves and corresponding does not resolve during puberty, puberty only identity labels that capture that experience. exacerbates their dysphoria. Like their peers Although we are unable to discuss here the full whose dysphoria resolves, they also feel fearful history of the looping efect as it has impacted and apprehensive about puberty; unlike their gender dysphoria,28 we have witnessed a shift peers, they find puberty to be just as difcult and over time in both the diagnosis (certainly from even traumatic as they had anticipated. “gender identity disorder” to “gender dysphoria,” Professionals have no reliable way of knowing in not to mention previous conceptualizations) and advance whose gender dysphoria will resolve and the interactions with the broader transgender whose will persist. This adds to the weight of community. These shifts in conceptualizations decisions families are making. and interactions, as well as the emergence of authorities who determine categorization and ways of understanding diverse gender identities, may also be contributing to emerging gender

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Alternative Ways to Manage Distress

Psychologists and counselors ofer several basic addition to their gender dysphoria, such as when coping strategies for a wide range of mental depression is present. Others use some of these health concerns, many of which can be applied to strategies in response to gender dysphoria itself, gender identity conflicts. However, these particularly if the gender dysphoria is less intense strategies have not been studied as protocols for and more manageable. the successful treatment of gender dysphoria, and many individuals who sufer from gender Faith-based coping strategies associated with dysphoria have tried various iterations of them. spiritual disciplines are also available. These These basic coping strategies include include such practices as corporate worship, identification and processing of negative afect reading of sacred texts, prayer, silence, fasting, (for example, feeling troubled, anxious, solitude, and the use of spiritual retreats. In one apprehensive, or dejected), deep (diaphragmatic) small study we conducted of Christians breathing exercises, muscle relaxation, and navigating gender dysphoria, one participant mindfulness strategies. Environment discussed the role of service: “Helping other management strategies can be used to limit people—focusing on the problems of others. I social situations that trigger gender-related was created to love God and love people. God distress or cause a marked increase in gender made me generous and empathic and that’s what dysphoria. For example, a biological female who matters.”29 Another Christian shared how she experiences gender dysphoria may limit social turned to God with questions about gender events in which the expectation is to dress in a incongruence as an enduring condition: “It wasn’t way that emphasizes her femininity (as when the until I got home and was journaling to God that expectation is to wear a dress). Social support is night that I started to cry. ‘I want to be normal,’ I another important coping strategy: having a told Him. ‘I don’t want to be proud of my identity. number of people you can turn to to be honest I just want to be normal. Oh God, I want to be about your difculties, people who will listen and normal.’ If there was a plan for me to be this way, be a source of encouragement to you. Learning why do I feel scared to be this way? I don’t have how to identify unhelpful, shame-producing an answer to that question.”30 thoughts (“I’m a complete failure because my gender identity concerns continue to be a part of Because gender dysphoria can reside along a my life”) and connecting them to behaviors (such continuum of intensity, it may be that many as isolation from others) and to emotions (such as people who experience gender identity conflicts shame) can also be helpful. Once these unhelpful draw upon the strategies mentioned above. As we thoughts are identified, they can be replaced with said, these are generic coping strategies that are more helpful thoughts (“Like everyone else, I am applied to many diferent kinds of negative afect imperfect, but that doesn’t mean I am a failure at or distress. We would not assume that a person life.”). Many people use these basic coping hasn’t tried any of these. You could ask what strategies to address co-occurring concerns in strategies people have employed, what’s been

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helpful and what hasn’t helped. It would be a reports and not prescribing pastoral counsel. mistake to expect coping strategies to be Christian leaders should integrate a holistic curative or a one-size-fits-all approach. Diferent Christian vision for human flourishing into their strategies help diferent people at diferent times. guidance.

When people are unable to cope with gender A biological female who identifies as transgender dysphoria through the kinds of coping strategies underscored the dilemma many Christians face, we’ve mentioned, some choose to use more and it is a dilemma that many pastors face in gender-inflected strategies. These strategies providing ministry to people sufering from more often involve “cross-gender activities,” insofar as intense gender dysphoria: “Transitioning is the society ascribes certain activities or dress or main secular response; healing through other experiences to one gender over another. counseling is the main Christian response. For example, in the study we mentioned above of Dealing with it daily is the reality for most of Christians navigating gender dysphoria, one us.”34 biological female who identified as transgender described the following coping strategy: “I dress As we bring this section to a close, please note a certain way to manage my dysphoria. Dressing that the strategies reviewed above are some ways as a tomboy helps. It’s easier for female-to-male. in which people have coped with gender I avoid situations when I would be expected to dysphoria; however, a pastoral or Christian wear a dress—situations with heightened gender counselor will want to explore a holistic Christian expectations. Black tie events. I understand approach to sanctification in terms of coping which situations push my buttons and avoid with gender dysphoria. them.”31

A participant who identified as genderqueer shared, “I usually just wait for it to pass. A few friends call me [preferred name] which feels more gender-neutral, but I haven’t really found anything that helps when the dysphoria gets strong.” 32

A participant who is a biological male and who identifies as gender dysphoric shared, “For now I manage my dysphoria by buying feminine jewelry like bracelets and necklaces and wearing it when I’m out by myself or with friends (none of whom yet know that I’m gender dysphoric). I sometimes cross-dress when I have the chance to be home alone. Once in awhile I’ll tuck my penis when I come out of the shower—it brings me a sense of relief.”33 Again, we are simply surveying empirical

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Pastoral Recommendations

In light of all this, how can pastors respond wisely point precisely because they have looked for and to people experiencing gender dysphoria? We tried many remedies for gender dysphoria and hope you have at least seen that pastoral have found them wanting. One-liners like those responses will likely vary based on the diferent above certainly bring difcult conversations to an experiences of what we might more broadly refer end, but they do not set the stage for ministry. to as gender identity concerns. We are unable here to develop all of the nuances of diferent Our recommendations will vary slightly based on experiences and how to respond to each one. your relationship with the person you are meeting However, the person diagnosed with gender with, their age, and whether they have adopted a dysphoria is often wrestling with how their cross-gender identity. For example, diferent experience of gender dysphoria fits into God’s considerations arise when a teen discloses plan for their life, and whether there is any way gender dysphoria in youth group, or when a that His glory could be shown through their person who has transitioned would like to attend experiences. They wonder about the morality of your church. How do you respond when a teen various management strategies and are tells you they want hormonal treatment? Do you desperately seeking answers. They have looked at encourage a person to pursue this or sex Scripture, but wonder why God seems “silent” on reassignment surgery, or do you rebuke them for how they can manage this. They want certainty even considering it? Do you recommended about what is morally permissible, and yet some detransitioning if a person comes to your church feel a sense of urgency to do something to cope after they have transitioned? What are the with their distress. This is especially true in cases implications on a marital relationship if one of the where dysphoria has risen to a level where the spouses is considering adopting a cross-gender strategies they are currently using do not seem to identity, or already has? You can see how help anymore. complicated these questions are, and we cannot possibly do justice to all of them. A pastor’s role in these considerations is essential, and we often encourage people we have met In ministry, there is often pressure to give with to go to leaders in their faith community answers. Your responsibility is not to be taken with their questions. In many cases, they did so lightly, since your role of shepherding people is and found that their leaders were similarly certainly unique. Our primary recommendation, confused. At other times, faith leaders were though, is to ask more questions before giving an overly confident that pat answers like “God “answer.” This may seem counterintuitive when doesn’t make mistakes” or “God made you this people are coming to you and looking to you for way and you ought to accept it” would be the guidance. Here we are, suggesting that you listen remedy for gender dysphoria, or at least the end and then listen some more. But this approach can to a difcult conversation. For most people yield far greater benefits than you might realize. considering transitioning, they have reached this People who experience gender identity conflicts,

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and their loved ones, have encountered many to take seriously the child’s experience, rather people before you who are ready to give answers than dispute it or label it as willful disobedience. It without really appreciating the challenges they is hard to imagine that anyone would choose the face navigating such difcult terrain. We cannot level of distress and challenge that comes from appreciate the challenges if we do not first invite experiencing gender dysphoria, even if someone to share about them, if we do not listen trans-trending is at play. with patience and gentleness. Some parents may come to you as they are One mother shared with us that, when she told a considering whether or not they could support friend about her child’s gender dysphoria, he their child in transitioning. This question can be confidently recommended she should take the overwhelming to someone in ministry who wants child shopping for dresses and set up playdates to help but who may not know how to think with other girls. He then said, “If you had not about the physical and psychological implications worked when she was young, you would have of the decisions the child is facing, to say nothing had more time to bond. But it’s never too late.” of those decisions’ moral implications. Do not Imagine the impact of his words on this mother. speak with confidence that there is an easy She had already tried taking her child shopping solution, as this only magnifies the isolation many for dresses. She had seen her daughter’s parents feel in their own confusion. It is more frustration at not being allowed to play with boys, helpful to enter into this space with humility and whom she was naturally drawn to. This mother receptivity to hearing the parents’ own concerns, had already faced the guilt of worrying that she rather than first expressing your own. had caused her child’s gender identity conflicts, as many parents do when their children have The number one predictor of child wellbeing over challenges they did not anticipate and would time is the strength of the parent-child gladly take away if they could. relationship. This is crucial to keep in mind as we minister to parents in this space. We often If you are a pastor, we imagine that parents are encourage parents to take a long-term view, even more likely to come to you than their children are. though they may feel a sense of urgency to Sadly, many young people we work with have respond with the right answers immediately. If abandoned Christian faith and would not seek out they want to develop a plan to protect their child, pastoral care because they expect Christian both from physical harm and from spiritual communities to reject them. When it comes to consequences that they worry about, this plan talking with parents, as our example above shows, should acknowledge that their relationship with it is much easier to describe what not to do in their child will develop and change in the coming ministry. Do not blame the parent for their child’s years. Some parents are concerned about the dysphoria. Refrain from trivializing their child’s impact of transitioning on a child’s social life, distress, even if it is not something you can relate fearing that bullying or harassment will take place to. We have met with parents who don’t ever if their child chooses one path over another. remember their child displaying gender atypical Other parents describe a grieving process that behavior in childhood, and this leads them to they go through when they discover that their doubt their child’s experience. We find it helpful child experiences gender dysphoria, and even

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more so if their child is considering or has panicked, as he assured me this was never pursued transitioning. Invite parents to share their covered in seminary. I encouraged the pastor to fears and pain, and ofer support like you would return the phone call, suggesting he accept the for other parents who may find it difcult to trust invitation to get the cofee and say something like that God will protect their children in the face of this: “I feel like I’m meeting you at about chapter 7 unexpected life circumstances or 8 of your life. I haven’t had the opportunity to hear about chapters 1 through 6, but I’d like to.” I We emphasize the value of maintaining assured my friend that this person had likely never relationships above all else. Whatever decisions heard this from a pastor before and that both are made regarding transition, gender dysphoria could learn a lot from their future conversations. brings weighty crosses for people to carry. We would do well to share the weight of these This alternative ministry posture is one of crosses, lest we forget that Christ called us to accompaniment. It models, in each interaction love one another as he loved us. For Christ, this with someone, the reality of Christ’s love was expressed through an invitation to come unconditional love for them where they are to him and cast our burdens upon him, with the today. It reflects his desire to meet us where we promise that he will sustain us and give us rest are, to know us here, to understand our lives (Psalm 55:22; Matthew 11:28). What does this regardless of where we have come from, and to mean for ministry? Perhaps this question is best journey with us wherever we go. This posture explored in the context of pastoring a person may be the door to further dialogue with who has transitioned, since this may be the path someone about how Christ might speak into their many Christians find most difcult to journey with life and their decisions in the future, while someone on. honoring the journey they are on. It allows you to embody the presence of Christ in the messiness Some people believe that the pastoral “answer” to of life by your very presence. A posture of a person who has transitioned is detransitioning. accompaniment emphasizes compassion—that is, However, regardless of whether a person’s sufering with one another—and is a hallmark of obedience to Jesus ultimately leads them to the Body of Christ when we function at our best. detransition, suggesting this in an initial It prepares you to provide pastoral care and conversation may not be wise or pastorally spiritual oversight. compassionate. It has an all-or-nothing quality, as if there are behavioral prerequisites for walking in We hope this resource hasn’t given you any the door. Consistency is important; it may be simple answers—it wasn’t our intention to dole helpful to reflect on how you would relate to out simple answers. Nor did we attempt to set others under your leadership who have walked forth a specifically biblical approach to sex and down paths you might not have chosen for them. gender. Rather, we hope you are better informed about what we know (and what we do not know) Several years ago, a pastor called, distressed about SRS and HT. We hope you’ll add this following a phone call with a middle-aged knowledge to your own Christian faith tradition transgender person who had transitioned and had and resources for pastoral care and counsel to recently begun attending his church. The person inform your ministry, so you can minister from a invited the pastor to get cofee. The pastor was place of greater wisdom and compassion.

PG. 15 THE CENTER FOR FAITH, SEXUALITY & GENDER

Notes

1. While some transgender persons may choose to pursue 8. Murad, Elamin, Garcia, Mullan, Murad, Erwin, and Montori. HT or SRS even though they have not been diagnosed with gender dysphoria, we are focused here on those who have 9. Manieri, C., Castellano, E., Crespi, C., Di Bisceglie, C., received the diagnosis of gender dysphoria. Gualerzi, A., & Molo, M. (2014). Medical treatment of subjects with gender identity disorder: The experience in an italian 2. Murad, M. H., Elamin, M. B., Garcia, M. Z., Mullan, R. J., public health center. International Journal of Transgenderism, Murad, A., Erwin, P. J., and Montori, V. M. (2010). Hormonal 15(2), 53-65. therapy and sex reassignment: A systematic review and meta-analysis of quality of life and psychosocial outcomes,” 10. Khatchadourian, Amed, & Metzer. Clinical Endocrinology 72, 214-231. 11. Karpel, L., Gardel, B., Revol, M, Bremont-Weil, C., Ayoubi, 3. Haas, A. P., Eliason, M., Mays, V. M., Mathy, R. M., Cochran, J., & Cordier, B. (2015). Psychological and sexual well being S. D. & D’Augelli, A. R. (2010). Suicide and suicide risk in of 207 after sex reassignment in France. Annales , , bisexual and transgender population: Review Medico Psychologiques, 173, 511-519. and recommendations. Journal of , 58(1), 10-51. 12. For a review, see Carroll, R. (2007). Gender dysphoria and transgender experiences. In Leiblum, S. R. (Ed.), Principles 4. Khatchadourian, K., Amed, S., & Metzger, D. L. (2014). and practice of sex therapy (4th ed.), (477-508). New York: Clinical management of youth with gender dysphoria in Guilford Press. See also, Johansson, A., Sundborn, E., Vancouver. The Journal of Pediatrics, 164(4), 906-911. Hojerback, T., & Bodlund, O. (2010). A five-year follow-up study of swedish adults with gender identity disorder. 5. Heylens, G., Verroken, C., De Cock, S., T’Sjoen, G., and De Archives of Sexual Behavior, 39, 1429-1437; Gooren, L. J., Cuypere, G. (2014). Efects of diferent steps in gender Giltay, E. J., & Bunck, M. C. (2008). Long-term treatment of reassignment therapy on psychopathology: A prospective transsexuals with cross-sex hormones: Extensive personal study of persons with a gender identity disorder. The Journal experience. Journal of Clinical Endocrine Metabolism, 93(1), of Sexual Medicine, 11(1), 119-126. See also Colizzi, M., Costa, 19-25; A. J. Kuiper and P. T. Cohen-Kettenis, “Sex R., & Todarello, O. (2014). Transsexual patients’ psychiatric Reassignment Surgery: A stud of 141 Dutch Transsexuals,” comorbidity and positive efect of cross-sex hormonal Archives of Sexual Behavior, 17 (1988), pp. 439-457. treatment on mental health: results from a longitudinal study,” Psychoneuroendocrinology, 39, 65-73; 13. A. J. Kuiper and P. T. Cohen-Kettenis, “Sex Reassignment Khatchadourian, Amed, & Metzer. Surgery: A study of 141 Dutch Transsexuals,” Archives of Sexual Behavior, 17 (1988), pp. 439-457; Lawrence, A. A. 6. Simonsen, R. K., Giraldi, A., Kristensen, E., & Hald, G. M. (2003). Factors associated with satisfaction or regret (2016). Long-term follow-up of individuals undergoing sex following male-to-female sex reassignment surgery. Archives reassignment surgery: Psychiatric morbidity and mortality. of Sexual Behavior, 32(4), 299-315; Gijs, L. & Brewaeys, A. Nordic Journal of Psychiatry, 70(4), 241-247. (2007). Surgical treatment of gender dysphoria in adults and adolescents: Recent developments, efectiveness, and 7. Colizzi, Costa, & Todarello. challenges. Annual Review of Sex Research, 18(1), 178-224; Karpel et al.

PG. 16 PASTORAL PAPER 10

14. Karpel et al. 27. Hacking, I. (1999). The social construction of what? Cambridge, MA: Harvard University Press. 15. Dhejne, C., Lichtenstein, P., Boman, M., Johansson, A. L., Langström, N., & Landén, M. (2011). Long-term follow-up of 28. For a more detailed account, see Mark A. Yarhouse & transsexual persons undergoing sex reassignment surgery: Julia Sadusky, chapter contribution in Paul Eddy & James Cohort study in Sweden. PLoS ONE, 6(2), 1-8. Beilby (Eds.), Transgender: Four Views. Grand Rapids, MI: Baker Academic. 16. Dhejne et al., p. 7. 29. Mark A. Yarhouse & Dara Houp, Transgender Christians: 17. Simonsen et al. Gender identity, family relationships, and religious faith. In Sheyma Vaughn (Ed.), : Perceptions, media 18. Shute, J. (2017). The new taboo: More people regret sex influences, and social challenges (pp. 51-65). New York, NY: change and want to ‘detransition’, surgeon says. National Nova Science Publishers, p. 58. Post,http://nationalpost.com/news/world/the-new-taboo- more-people-regret-sex-change-and-want-to-detransition- 30. Yarhouse & Houp, p. 59. surgeon-says 31. Yarhouse & Houp, p. 58. 19. http://guideonragingstars.tumblr.com/post/14987770617 5/female-detransition-and-reidentification-survey 32. Ibid.

20. https://docs.google.com/document/d/1wBW-gUrJo2hW 33. Yarhouse & Houp, pp. 58-59. 2C5lBgl_Ash5fuTDbRki0Vqh0DcjU88/edit 34. Yarhouse & Houp, p. 59. 21. https://docs.google.com/document/d/1nc5X96PwzyfIfpv Ki8RQR5t9AQe9SVl76aWZL30rVLY/edit

22. http://nationalpost.com/news/world/the-new-taboo-m ore-people-regret-sex-change-and-want-to-detransition-s urgeon-says

23. Zucker, K. J. (2017). Epidemiology of gender dysphoria and transgender identity. Sexual Health, https://doi.org/10.1071/SH17067

24. Kaltiala-Heino, R., Sumia, M., Tyolajarvi, M, & Lindberg, N. (2015). Two years of gender identity service for minors: Overrepresentation of natal girls with severe problems in adolescent development. Child and Adolescent Psychiatry and Mental Health, 9(9), 1-9.

25. Ibid.

26. Zucker, p. D.

PG. 17 About the Authors Our collaboration is a growing team of Christian leaders, pastors, scholars, and LGBT+ persons to serve as advisors, writers, speakers, researchers, and board members. Learn more about our collaborative team at www.centerforfaith.com/leadership.

Mark A. Yarhouse, Psy. D. Julia Sadusky, M.A. Writer / Advisor Writer / Advisor The Center for Faith, The Center for Faith, Sexuality, & Gender Sexuality, & Gender

Dr. Mark Yarhouse is the Rosemarie S. Hughes Julia is in her fourth year in the Doctoral Program in Endowed Chair and Professor of Psychology at Regent Clinical Psychology at Regent University. She obtained University, where he is the executive director of the a Bachelor's Degree in Psychology from Ave Maria Institute for the Study of Sexual Identity University, and minored in Theology and Family & (www.sexualidentityinstitute.org). Mark is the author or Society. She then attended Regent University where co-author of several books, including Understanding she received a Master's Degree in Clinical Psychology. Sexual Identity: A Resource for Youth Ministry and At Regent, her research experiences and clinical Understanding Gender Dysphoria: Navigating training have focused on the study of sexual and Transgender Issues in a Changing Culture. gender identity. She serves as Research Assistant in the Institute for the Study of Sexual Identity, and provides services through the Sexual & Gender Identity Clinic at the Psychological Services Center.

The Center for Faith, Sexuality & Gender is a collaboration of Christian pastors, leaders and theologians who aspire to be the Church's most trusted source of theologically sound teaching and practical guidance on questions related to sexuality and gender.

Download more resources at: WWW.CENTERFORFAITH.COM