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.