I have a friend who served for a time as a pastor in the Midwest before transitioning into a medically-related field, because his job as a pastor didn’t pay enough to cover the bills after he and his wife adopted several children, with at least one having some special needs. During a conversation a few years ago, he volunteered that he serving part-time as a volunteer pastor at a growing church plant near his home.
My friend was enthusiastic about his church. To illustrate, he shared that one of their attendees was a man who came to church every Sunday morning in a wig, makeup and women’s clothing. My friend was very pleased that the stuff going on in his new church was compelling enough to draw this person into what was likely a very uncomfortable situation for someone of his appearance, but was more pleased by the way the people of his church welcomed him, accepted him into the congregation and treated him with respect.
It’s easy for those of us in Christian culture to lump people who fall under the “LGBTQ” designation into one big category in how we think about their lifestyle and behavior, but in my experience as a psychiatrist, there’s something qualitatively different about the complexity of mental health issues in people who struggle with gender dysphoria. For all the media attention Bruce Jenner received for pursuing medical and surgical treatment to change his anatomy and appearance to resemble a woman, the percentage of people in society who struggle with gender identity is very small. The handful of kids and adults with gender dysphoria I’ve come across entering my thirtieth year in psychiatry have experienced quite a bit of mental anguish. As part of our mission to build bridges between the church and families served by the mental health system, I thought I’d review the research literature to see what we know about adults who struggle with gender dysphoria…I’ll tackle the research on children and teens in an upcoming post.
The American Psychiatric Association very publicly removed “Gender Identity Disorder” from the DSM-5 in 2013, in exchange for the term “Gender Dysphoria,” which merits its’ own chapter in the new diagnostic guidelines. You can read more about their rationale here. The APA is careful to emphasize that gender dysphoria doesn’t represent a mental disorder. At the same time, adults with gender dysphoria experience symptoms of mental illness at much higher rates than the general population.
Here’s a 2010 study from the National Center for Transgender Equality and the National Gay and Lesbian Task Force examining healthcare access issues in a sample of over 7,000 adults who self-identified as either transgendered or gender non-conforming. I found the survey very helpful in understanding the continuum of medical and surgical treatment in this population…the majority of adults have received hormonal therapy, a minority have received some surgical treatment, but relatively few have complete the entire series of procedures involved with the gender reassignment surgery that Bruce/Caitlyn experienced. I’ll share some highlights…
- 75% of respondents reported having received counseling associated with their gender dysphoria…an additional 14% hoped to receive counseling someday.
- Participants reported rates of cigarette smoking around 50% higher than rates in the general population.
- 41% of the overall sample reported having made a suicide attempt in their lifetime- the rate in the U.S. adult population is 1.6%
- In contrast to the general adult population, lifetime rates of suicide attempts are higher among members of ethnic minorities identifying as transgendered or gender dysphoric (see graphic at right)
- Despite many studies reporting improved self-esteem and sense of well-being following medical and/or surgical treatment, rates of attempted suicide were higher among adults who had medically (45%) or surgically (43%) transitioned, compared to adults who had not transitioned (34% and 39%, respectively.
One big red flag in the data describing outcomes among adults who undergo gender reassignment surgery is the data surrounding suicidal behavior following surgery. A review of the research literature produces lots of papers containing radically different claims about mental health outcomes in patients who undergo gender reassignment. For example, this long-term study reports very positive outcomes in 71 patients when compared to their status at the time of intake. I was struck by this study of patients who underwent gender reassignment surgery in Sweden over a 30 year period. Some key findings…
- Following surgery, patients were four more likely to have been hospitalized psychiatrically for a condition other than gender dysphoria. The increased risk for psychiatric hospitalization persisted even after adjusting for psychiatric hospitalisation prior to sex reassignment.
- Rates of death by suicide soared ten years or more following surgery. The rate of completed suicide in this study following gender reassignment surgery was NINETEEN TIMES HIGHER than the rate in the general population.
Dr. Paul McHugh, the former chairman of psychiatry at Johns Hopkins University Medical School…the academic center where many of the techniques used in gender reassignment surgery may be among the most outspoken (and controversial) figures in the debate about treatment of gender dysphoria. Here’s a link to an article he authored in First Things and a more recent article in the Wall Street Journal. From the First Things article…
The psychiatrist and psychoanalyst Jon Meyer was already developing a means of following up with adults who received sex-change operations at Hopkins in order to see how much the surgery had helped them. He found that most of the patients he tracked down some years after their surgery were contented with what they had done and that only a few regretted it. But in every other respect, they were little changed in their psychological condition. They had much the same problems with relationships, work, and emotions as before. The hope that they would emerge now from their emotional difficulties to flourish psychologically had not been fulfilled.
We saw the results as demonstrating that just as these men enjoyed cross-dressing as women before the operation so they enjoyed cross-living after it. But they were no better in their psychological integration or any easier to live with. With these facts in hand I concluded that Hopkins was fundamentally cooperating with a mental illness. We psychiatrists, I thought, would do better to concentrate on trying to fix their minds and not their genitalia.
It’s important to keep in mind that Dr. McHugh’s opinion is an outlier in the medical field, and the current accepted standard of care is medical (hormonal) or surgical treatment. Most patients who undergo treatment appear to be satisfied with the results, but based upon the statistics, an extraordinarily (and unacceptably) high percentage of patients experience sufficient emotional distress to attempt to take their lives. The suicide rates before and after treatment are scandalous. I worry that people with gender dysphoria and mental illness will be victims of an environment of political correctness, in which advocates for transgendered individuals will want to sweep very serious mental health concerns under the table because of fear of stigma from being diagnosed with mental illness.
Experts understand little of the causes of gender dysphoria. One theory suggests that prenatal exposure to high levels of androgens may be a factor. Other associations include later birth order, left-handedness, low birth weight and a higher number of male siblings. Some of the research being conducted into linkages between gender dysphoria and specific mental health conditions is fascinating, including higher than expected rates of schizophrenia, obsessional interests and autism.
In my experience, people with gender dysphoria are frequently intensely unhappy and battling serious mental illness. One of my patients asked me about Bruce/Caitlyn yesterday and I told him he would NOT want to experience what Bruce experienced.
I would certainly hope that my church would be a place where Caitlyn and others with similar issues would experience community and feel accepted. Despite their efforts through hormonal therapy and/or gender reassignment surgery to radically alter their God-given bodies, they’re still image bearers. I’d hope church would be a place where they could explore the claims of Jesus and experience peace. An unacceptably high percentage of those with gender dysphoria experience true “hidden disability” related to mental illness.
My friend’s church “gets it.” I’m pretty sure mine “gets it” too. I’m not sure most churches do.
Photo of Caitlyn Jenner from Vanity Fair.
My question here is what is Bruce looking into a church, acceptance or the truth that guides him to Christ? I agree that we should welcome him the same way we welcome the adulterous, or every other sinner, and try to avoid the cultural stigma.
Jose…thanks for posting.
There was a great post this morning over at Huffington Post (I went to church with Bruce Jenner and here’s what Caitlyn taught me about Jesus) that got yanked down within an hour of when I saw it. The guy who wrote it was the founding worship/youth pastor at a church plant in Calabasas that the Kardashian family helped launch. He wrote that the Kardashian’s were actually hosting small groups for teens at their house that the two younger girls attended for a long time. As the family became bigger and bigger media stars, they drifted away, but Bruce kept attending church on Sunday. The pastor who wrote the blog piece accepted a position at another church and left before Bruce went through the hormone therapy and gender reassignment surgery. The impression was left that Bruce is either a believer or someone who was authentically seeking at the time.
The Kardashians are famous mainly because Kim K. is an amateur porn star, and considering that pornography is evil from both a spiritual and a secular psychological perspective, it’s ridiculous that anyone would put faith in that family. Leaders should be better than the rest of us, not worse.
My faith is in Jesus until anyone else comes along who demonstrates they can raise themselves from the dead by their own power.
So do you think this is not sin but an illness? If it is not a sin I would think it would mean that the individual is incapable of surrendering to Jesus Christ. I understand how difficult it is for those born with these problems, but are they incapable of obeying. It would mean a life time of suffering – many have been called by God to endure a lifetime of suffering. Romans 8. How do we help them come to an understanding that God will give them the strength to walk with Him if they surrender. All sin is an attempt to make ourselves happy, ease a pain, satisfy ourselves apart from God; in doing so we break God’s law. I would think the primary way is through prayer – only the Triune God can draw any individual to Himself. I have been praying for Bruce.
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do you think jenner is any less capable of obeying than the rest of us? romans 8 (the passage you cited) reminds us that it’s the power of the Spirit that allows us to walk with God.
I don’t know Barry – that is my question. Is it possible that his brain is so hardwired such that he is incapable of even surrendering to God as I believe the Bible teaches is needed for salvation. Albeit – even I can’t surrender to God unless the Triune God gives me the desire and strength to do so. See below to see where I sit right now 🙂
Thanks for responding…this situation raises MANY questions that cause us to reflect on the teachings of our faith. I’ll share a few ideas that motivated me to blog about this…
First, we’re doing a blog series on welcoming and including families in church impacted by mental illness, and the extraordinarily high rates of attempted suicide reported among people with gender dysphoria before and after hormonal/surgical treatment suggest that among “sexual minorities” they are especially vulnerable to mental illness. While we all bear moral responsibility for our behaviors because we have a just God, and face the reality that WE ALL FALL SHORT of the required standard to enter into the presence of God (perfection), it would appear that the subset of our neighbors with gender dysphoria have an especially heavy cross to bear. How are they to come to know of God’s love and mercy and discover the truths revealed in Scripture if they don’t first experience grace?
Second, when people with gender dysphoria turn to our society’s healers in their distress, they’ll be told that “gender reassignment” is the treatment of choice. As a psychiatrist, I have to agree with Dr. McHugh that hormonal/surgical treatment is a very interesting approach, because we have a number of other conditions in psychiatry in which an individual’s perceptions of their body clearly are at odds with objective reality, and in NONE of those conditions (body dysmorphic disorder, anorexia nervosa, some cases of OCD or psychotic illness, or “transability“…the proposed category in the “emerging methods and models and methods” section of the DSM-5 identified as Body Integrity Identity Disorder) does treatment involve medically or surgically altering the body to fit within that person’s mental construct of their body. And while it’s unquestionable that many people obtain relief from gender reassignment, imagine what we would see in the media if Medicare agreed to pay for a new treatment (say an antidepressant?) associated with a 40%+ rate of suicide attempts following treatment…a significantly higher rate than seen in a control group that didn’t receive the treatment?
In our “politically correct” culture, there’s incredible momentum to de-pathologize gender dysphoria. I fear in doing so the medical/psychiatric community will be compelled to ignore pain and suffering that doesn’t fit within the cultural narrative. Let’s say that someone identified a genetic or biological cause of gender dysphoria amenable to some type of treatment…would they find a research review board that would approve the study, and would they still have a livelihood if their treatment worked? Where do the 43-45% who attempt suicide AFTER treatment for gender dysphoria turn to for help? As crazy as it sounds, they might turn to the church (as Bruce Jenner apparently did). How will we respond?
Finally, in response to your question about whether “this” is sin or an illness,.. I’d suggest it’s a manifestation of the brokenness that characterizes our fallen world and is a departure from God’s original design as reflected in Genesis. Our 21st century culture teaches an understanding of personal liberty described by one Supreme Court Justice as “the right to define one’s own concept of existence, of meaning, of the universe, and of the mystery of human life.”
I’m reminded of the exchange between the Apostle Philip and the Ethiopian in Acts 8: 29-31…
And the Spirit said to Philip, “Go over and join this chariot.” So Philip ran to him and heard him reading Isaiah the prophet and asked, “Do you understand what you are reading?” And he said, “How can I, unless someone guides me?” And he invited Philip to come up and sit with him.
Without God first freely extending His grace and the acceptance of that grace through faith, followed by guidance and conviction resulting from the indwelling presence of the Holy Spirit, how is someone with gender dysphoria raised in a culture that tells everyone that they are free to determine for themselves right from wrong begin to comprehend why some choices might be sinful?
Romans 2 would appear to make clear that their internal conflict is evidence of their capacity to accept and recognize their need for grace. This may be why those most determined to exercise self-determination in our culture related to matters of sexual liberty are quick to label any statement or comments drawing attention to these pangs of conscience as “hate speech” or “micro-aggression” because they point out the very uncomfortable truths described by Paul in this passage of Scripture.
Bottom line…the question we as Christian leaders need to wrestle with is how should we best reflect the Gospel to people struggling with gender dysphoria? Jesus was able to perfectly extend and reflect grace without compromising truth. We as the church are called to imitate Him as best we can with the assistance of the Holy Spirit.
Dr. Grcevich thanks for your response. I agree with almost all you said. I too believe we must welcome them to attend our churches, we must pour love out upon them; however what does that look like?
Apart from truth there is no grace. What have I given a person if I pour out human love upon him without speaking truth; or allowing him to believe he is going to heaven but he hasn’t surrendered to Jesus so he isn’t going to heaven.
I have a friend whose son-in-law is schizophrenic. He claims to love God but then he does things, like beat his child, which is horrid. His wife had to leave him to protect his children. He is not allowed to speak on the phone with his children due to the strange things he says to them which terrifies him. He does repent after all of these things so I do believe he loves God even though due to his mental condition he has to remain distant from his family.
How would you compare the spiritual struggle of a schizophrenic with a transgender?
God obviously created each person to be who He wanted them to be. Psalm 51, 139, Jeremiah 1. Key for each one of us is surrender. 1 John 3 makes it clear that no one who continues to wilfully sin walks with God.
What I believe as I sit here at this moment. Because I don’t know how much the brain is causing the person to do what he is doing I can only see what he is doing on the outside. To not accept who God made me to be, even though it is a horrid struggle and very painful, is a sin. If i want to walk with God I must be willing to surrender myself to slavery, I no longer own myself, I am owned by God. Therefore I must explain this to the person in as loving a way as I can. What he chooses is between him and God. If he chooses to reject who God made him and the walk God chose for him I will have to share that I still love him but I do not believe he knows God. Seeking to be somebody other than who God created me to be is turning my back on God.
Are you familiar with Sy Rogers? I am not was just told of him today. http://syrogers.com/sy-resources/
There is also this story http://www.theblaze.com/contributions/for-most-of-my-life-i-wished-i-had-been-born-a-boy/
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I’m bothered by two things about Bruce Jenner:
1) He thinks superficial, materialistic stereotypes make him a woman.
2) He thinks risky plastic surgery is a solution to a person’s problems.
And these issues have nothing to do with his gender, so no reasonable person should accuse me of being “transphobic.”
It’s just like when I condemn homosexuality. In the same breath, I will also condemn heterosexuals who use birth control, because I think they’re almost following the same philosophy.
I’m not discriminating against groups of people. I’m looking for a common set of rules to apply to all behavior.
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In Belgium there is also a very high rate of transgender suicides. I am not talking so much of those who have not had the surgery for transition, but the suicide rate applies to those who already HAD the surgery. What they have found is that many struggled with some form of mental illness beforehand. Children and teens are more vulnerable than ever because they are being manipulated into gender dysphoria acceptance at their most crucial time – when they are still growing and their frontal lobe cortex of the brain is not completely grown which is where all the decision making, comprehension and reasoning take place. Parents are blindly leading their children/teens into a lifetime of difficulty, pain and life altering challenges that very much could lead them to be the next suicide victim.
As to the issue of sin…I will liken it to those with certain mental illnesses, some people do not have the capability to understand the difference of acting upon something that is wrong compared to acting upon something they are confused about. For example, the viewer who mentioned about the man with schizophrenia who was violent. Gender dysphoria is like a mental game. Their mind and heart are telling them one thing and their body is saying something else. Then you add the component of spirituality and they will struggle with identity crisis of who they are, why did God make them like that, were they created like this on purpose or as a freak accident, and many more questions that leave them with no answers. As to Bruce Jenner, only God knows his heart. We are called to pray for him. As to transgenders in the Church – love them as Christ loved the Church but also encourage them to heavily seek the Lord and pray that God will heal the broken part of them. If they TRULY love the Lord, they will find peace and it will be confirmed by those who know them. When Christ returns, that transgender man or woman would finally be made whole.