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A Review of Mark Yarhouse's "Understanding Gender Dysphoria"

Austen Hartke4 Comments
 Photo by  Howard Lake  on Flickr

Photo by Howard Lake on Flickr

Since Caitlyn Jenner's official coming out on the front of Vanity Fair two months ago, more media attention has been focused on transgender issues than most of us ever thought possible. From The Atlantic to The New Yorker to Christianity Today to The Blaze--everyone wants a story and everyone wants to publish an opinion. In Christian circles, responses have run the gamut from absolute acceptance to vilifying denouncement, but one thing is sure--church communities are asking questions and formulating responses to something that wasn't on the radar for most ten years ago.

Into this fray jumps Christian psychologist Mark Yarhouse with his book "Understanding Gender Dysphoria: Navigating Transgender Issues in a Changing Culture." Dr. Yarhouse's book attempts to find a harmony in the midst of conflicting opinions by calling for an "integrated framework" that balances conservative evangelical biblical views with medical and psychological concepts of disability and the celebration of diversity found among those of us who work for social justice. Think that sounds like a lot to try to weave together? You'd be right.

And though there have been several reviews done of Dr. Yarhouse's book (I'd recommend this one for its thorough summary and critique), I have yet to see one written by a transgender Christian. Dr. Yarhouse says, when describing his preferred method of therapy: "Narrative therapy focuses on the role of socially constructed 'scripts' in a person’s life. What is perhaps most interesting about narrative approaches to therapy is that they are often used with marginalized groups whose 'story' has been written by a dominant culture. On a larger level, entire groups of people could have their story about themselves completely overtaken by a more dominant group's story about them." Unfortunately, I believe this is exactly what Dr. Yarhouse's book has done--it has created a narrative about the causes, effects, and meaning behind gender dysphoria that is palatable to conservative Christians, all the while ignoring the voices of transgender Christians themselves.

But before diving further into that particular critique, let's take a very brief look at the book itself:

  • Dr. Yarhouse's first chapter covers basic terminology and a short history of transgender people in the media, beginning with Christine Jorgensen. He also makes it a point to say that people who experience gender dysphoria (he dislikes using "transgender" as a descriptor) are not intentionally moving away from God or being willfully difficult.
  • The second section "A Christian Perspective on Gender Dysphoria" skims very briefly over biblical scholarship and theology, focusing primarily on 1 Corinth. 6:9-10; Deut. 22:5; Matt. 19:12 and Acts 8:26-39, and citing the Evangelical Alliance Policy Commission on Transexuality and Robert Gagnon as major sources. Next, we are introduced to Yarhouse's three frameworks for understanding gender dysphoria and transgender identities. The Integrity Framework is based in conservative evangelical belief in complementarity and the existence of only two genders/sexes. Yarhouse says "cross-gender identification is a concern in large part because it threatens the integrity of male-female distinctions.” The Disability Framework is based in conservative psychology that sees gender dysphoria as a mental illness. Here, “gender dysphoria is viewed as a result of living in a fallen world in which the condition—like so many mental health concerns—is a nonmoral reality… That nonmoral reality reflects one more dimension of human experience that is ‘not the way it’s supposed to be.’” Finally, the Diversity Framework “highlights transgender issues as reflecting an identity and culture to be celebrated as an expression of diversity.” Yarhouse breaks up the diversity framework into a “strong form” and a “weak form,” the former including those who would like to deconstruct gender norms entirely, and the latter including those who don’t want to get rid of gender norms but would like to make more room for those who don’t fit the norms easily. Yarhouse is clearly uncomfortable with the “strong” diversity framework, and is only slightly more tolerant of the weak form, but cites some of its benefits including it’s ability to give someone a sense of identity, community, and belonging.
  • In the third and fourth sections of the book, Yarhouse tries to summarize the possible causes of gender dysphoria and to give a sense of what gender dysphoria actually looks like in research and in the psychologist's office. Most of the research appears sound, with the exception of Blanchard's Typology, which is used liberally throughout the book, and will be discussed below. It is also worth noting that the only study on transgender Christians which is referenced in the entirety of this work is a study on MTF (male-to-female) transgender Christians undertaken by Yarhouse himself.
  • Section five talks about the prevention and treatment of gender dysphoria, in psychological terms, from childhood to adulthood. Yarhouse suggests several different ways of dealing with gender dysphoria in childhood, including the “wait and see” model which allows children to work things out on their own, while also mentioning harsher models that reward children for presenting and acting according to the norms of their assigned gender while keeping them away from anything associated with the “opposite” gender. Yarhouse states that his end goal is to encourage those who “experience gender identity conflicts to resolve the conflicts in keeping with their birth sex if possible” and only to manage gender identity conflicts “through the least invasive means (recognizing surgery as the most invasive step toward expression of one’s internal sense of identity).”
  • Finally, sections six and seven attempt to formulate a “Christian response” to people with gender dysphoria, first at individual and then institutional levels.

I'll admit, this was a difficult read for me. Though it's not surprising that a clinical psychologist would come to the conclusion that transgender identities are a form of mental illness or disability, it was still difficult to see the way that outcome informed the creation of initiatives for things like prevention and correction. Having said that, as I read through Dr. Yarhouse's book I found that I didn't so much take issue with his conclusion, as with the research that led to that conclusion. My major critiques of this work are as follows:

  1. Skewed Data - Dr. Yarhouse constantly prioritizes and uses data from and concerning MTF (male-to-female) transgender patients. This use of data might not have been a problem in and of itself, as it is a fact that there is more data available on MTF patients. The issue I take with the use of this data is that these studies on MTF patients are cited as generalizations to cover all transgender people equally, despite only representing one part of the community. It excludes FTM and non-binary transgender experiences, which are necessary for a complete analysis.
  2. The Blanchard Typology - Dr. Yarhouse relies heavily on the Blanchard Typology, which categorizes transgender people based not just on their gender experience, but also on their sexual attraction. Ray Blanchard, working in the 1980s, theorized that transgender people could be split into three groups. The first is the "male-to-female androphilic type," which includes MTF women who are attracted to men, who transition at a young age, and who recall childhood femininity. The second is the "male-to-female autogynephilic type," which Yarhouse says "is described more like a fetish. In this case proponents assert that the biological male finds the idea of himself as a woman sexually arousing." Blanchard says these individuals tend to transition at an older age, report more cross dressing and less childhood femininity. Blanchard's third type is simply called the "female-to-male" type, and includes all those assigned female at birth who identify as male, and who are attracted to women. As anyone who is LGBTQI or A can tell you, these types are so much hogwash in the face of the many different ways individuals experience their gender identity and their sexual orientation. The fact that a typology like this is used at all, which conflates gender identity and sexuality, which pushes trans men off to the side, and which categorizes trans women based on the age at which they decide to transition, is frankly amazing.
  3. Lacking in Theological Discourse - Despite designating a whole section to a theological understanding of gender identity and dysphoria, Dr. Yarhouse's book comes up decidedly short when it comes to showing the work. It seems as if Yarhouse is speaking primarily to conservative evangelicals, and so he supposes that they are all on the same page from the beginning--that page being titled "cross-gender identification is morally wrong." What we don't see here is any discussion of WHY this might be. What reasoning is given is based heavily on complementarity and the writing of Robert Gagnon, which can be easily answered with James Brownson's book "Bible, Gender, Sexuality."
  4. Lack of Support for "Least Invasive Means" Conclusion - Throughout the book Dr. Yarhouse voices his support for using the "least invasive means" for managing gender dysphoria. He would not encourage a patient to move forward with hormone therapy, for instance, if the trans person could "deal" with their dysphoria through wearing different clothing instead. For Yarhouse, surgery is the very, very last resort. But consider that Yarhouse quotes a study by Richard Carroll that says “It appears now that the majority of adults with gender dysphoria cannot, or will not, completely accept their given gender through psychological treatment.” And furthermore, he later references this series of studies: "One author reports that about three-fourths or more of those who complete sex-reassignment surgery report satisfaction with their new identity and only about 8 percent report poor outcomes with surgery. Others have reported that only about 2 percent actually regret sex-reassignment surgery with 4 percent expressing dissatisfaction with the surgical outcomes. A recent study that examined outcomes over a fifty-year period in Sweden (1960–2010) indicated a 2.2 percent rate of regret for both MtF and FtM transsexual persons." With the rate of regret so incredibly low, and with studies showing that psychological treatment only staves off the inevitable in the majority of cases, what basis is there for a bias against physical transition? I can only conclude that Dr. Yarhouse's reticence is based on his theological beliefs, which, as I noted above, were not well spelled out here.
  5. Lacking in Transgender Christian Voices - As I mentioned above, the only transgender Christian voices heard in Dr. Yarhouse's book came from his patients--those he saw in practice and the MTF individuals in a study which he himself conducted. This lack of voices is noticeable. At one point, in a story about a MTF patient named Ella who suffered from gender dysphoria, Dr. Yarhouse asks "Is it too much to say that it is in this context of suffering that both meaning and identity are found?” If this question was directed toward me, or any other trans Christian I know, we would be quick to point out that while suffering is inevitable in this life, there is a difference between unavoidable suffering and suffering caused by others because of a different system of beliefs. We cannot treat suffering caused by other people as if it's an "act of God" like a hurricane or an avalanche. Meaning and identity may be found through suffering, yes, but that doesn't justify the human actions that created that suffering. In the same way, when Dr. Yarhouse supposes that a trans person might experience a church that does not denounce them as "gracious and supportive," I have to wonder--what if he had actually asked a trans Christian how they would feel, instead of assuming? The trans people of faith I know ask more of a church community than just "please don't run me out the door." To us, a "gracious and supportive" church looks like a place where we are actively included, and not just tolerated, and I expect Dr. Yarhouse would know that had he given trans Christians the platform to speak for themselves.

Having said all that, I'll take one more minute to highlight a couple of the things I believe Dr. Yarhouse did right. Above all, I appreciate his desire to decrease the number of people who see gender dysphoria as willfully sinful, and to increase a sense of compassion among those who disagree. Even if I personally take issue with his conclusion (that gender dysphoria is a mental illness to be prevented), I appreciate that it draws people away from a harsher kind of condemnation. It's a step in the right direction, even if it is a small one. Additionally, I appreciate his recognition that "If Christians simply shout 'Integrity, integrity, integrity!' and 'Sacred, sacred, sacred!' in discussions about gender dysphoria, we will fail to appreciate ways in which these other frameworks inform how people who experience gender dysphoria navigate difficult and quite complex decisions throughout their lives. In the end, Christians who rely solely on the integrity framework may shore up borders within the local church, but we will actually fail to engage those within the broader culture who are watching these exchanges, and I suspect we will drive gender dysphoric persons away from Christ and away from Christian community.” Having made this observation, I hope that Dr. Yarhouse will find a way to incorporate transgender Christian voices into his future work, rather than holding the categories of "transgender people" and "Christians" in separate hands as if the two never meet.

I also pray for a day when books like this, which are heralded as the definitive guide to a group of people, may actually be written by someone from within that group. Remember that there are no voiceless people--only those we refuse to hear.