“For all intents and purposes, I am a woman. People look at me differently. They see you as this ‘macho male’, but my heart and my soul and everything I do in life- it is part of me, that female side is part of me. It’s who I am. I was not genetically born that way. As of now, I have all the male parts and all that kind of stuff… But we still identify as female. And that’s very hard for Bruce Jenner to say. Because why? I don’t want to disappoint people.”1
In 2015, American Olympic hero (then called) Bruce Jennner announced to the world, in an interview with ABC’s Diane Sawyer, that Jenner was a woman. This interview changed the world. In the past few years we have seen a seismic shift in the way Western societies view transgenderism. Only a few years ago, the prevailing view of transgenderism was that of rare idiosyncrasy warranting medical intervention and encouragement towards desistance. But now, through hard fought campaigns led by Jenner and others, most people in the UK now see transgenderism as a celebrated and immutable part of our diverse society, although significant discrimination is still widespread.
But with this huge shift in societal thinking has come some challenging ethical questions. Should everyone have access gender reassignment therapies, regardless of age or situation (or should there be minimum criteria)? Who should have access to specific gendered bathrooms and changing rooms- and would liberal laws compromise safety? Should children be raised gender neutral? The questions could go on.
The ethics of transgenderism is a huge topic and I can only scratch the surface here. And so, in this article I am going to be focussing specifically on the medical and psychological issues. I hope to write another article soon on the political and legal questions around transgenderism.
I am going to be attempting to answer four main questions:
- How should we conceptualise transgenderism?
- What causes transgenderism?
- Are gender reassignment therapies ethical?
- What does the bible say into these questions?
1. How Should We Conceptualise Transgenderism?
In his book “Understanding Gender Dysphoria”, professor of psychology Mark Yarhouse lays down what he believes are the three prevailing “frameworks” by which people conceptualise transgenderism2. I find his summation helpful. However I, like Yarhouse, would argue that although all of these frameworks make good points, they are all also deficient in some way. The three frameworks are: the integrity, the disability and the diversity frameworks.
The “integrity framework” states that gender is incontrovertibly linked with biological sex, as the integrity between the two is God-given and sacrosanct. Therefore, to live as the opposite gender to ones biological sex, or even to feel an incongruence between sex and gender, is an act of immorality. Unsurprisingly this framework causes great offense, especially to members of the transgender community who argue that their transgenderism is a fact of their identity, not a moral choice. Also, I find that many proponents of the integrity framework base their views on fairly flimsy handling of tenuously relevant bible verses (often ripped out of context).
The “disability framework” states that transgenderism should be seen as a medical diagnosis, and is akin to conditions such as body dysmorphia (where patients have a fixed incorrect belief about the shape/size of their body). Some argue that transgenderism per se is not a medical condition, but gender dysphoria (the distress associated with incongruence between sex and gender) is. This is where current clinical guidance sits; DSM-V (one of the two main psychiatric diagnostic manuals) states that a diagnosis of gender dysphoria can be made if there is “a difference between one’s experienced/expressed gender and assigned gender, and significant distress or problems functioning” lasting at least six months. However, the disability framework also has issues. It also causes offense among those who view their transgenderism as an intrinsic part of their identity, rather than a psychiatric illness that needs treating. It also raises the controversial idea that clinicians should be managing transgenderism with psychotherapy and psychotropic drugs to change people’s perception of their gender, rather than accepting people’s gender identity and facilitating a life and body that accords. This is certainly an unpopular approach.
The “diversity framework” sees transgenderism as something to be celebrated and honoured as part of normal human diversity. The most strident proponents of the diversity framework then argue that gender as a concept should be deconstructed entirely. The diversity framework is increasingly the most popular framework in Western societies. However, it still leaves some difficult questions unaddressed. How should we address the distress and mental health issues that often accompany gender dysphoria? What do we do with the undeniable differences between the biological sexes- in medicine, law etc? And what moral framework should we use when dealing with ethical questions around reassignment therapies or bathroom laws?
In his book, Yarhouse proposes a middle-way “integrated framework” that combines the reverence of the integrity framework, the compassion of disability framework and the tolerance of the diversity framework. I agree, although to begin to formulate a coherent and compressive framework, it is helpful to first ask: what causes transgenderism?
2. What Causes Transgenderism?
The short answer is- we do not know.
The most popular explanation for the aetiology of transgenderism is so-called “brain-sex theory”. This theory proposes that there are areas of the brain that are different between biological males and females, called “sexually dimorphic structures”. And the idea is that biological males who self-identify as females have sexually dimorphic structures more similar to biological females (and vice versa). This resonates with the powerful sense many transgender people have that they are trapped in the body of the wrong sex. However, the neurological evidence for brain-sex theory is thin.
The most cited study is Zhou et al. (1995) who studied a part of the brain called the “bed of the stria terminalis” (BSTc) in 6 male-to-female (MtF) transsexuals3. They found that the BSTc was larger in cisgender males than in cisgender females, and “female-sized” BSTcs were found in MtF transsexuals. However, these results are based on a very small sample size, and the results may have been confounded by the fact that all participants were using feminising hormone therapies.
In addition, a subsequent study by Chung et al. (2002) showed that the differences between the BSTc of males and females actually develop in adulthood rather than in childhood4. The contradicts the testimony of many transgender individuals that report that their gender incongruency began pre-adolescence.
In addition to the neurological studies, there have been various other studies that have hypothesised psychosocial factors that may contribute to the aetiology of transgenderism, such as parental encouragement/hostility5, peer group behaviour6, and propensity to anxiety and sensitivity7. However, these studies are generally limited by small study size, and draw correlatory, rather than causal, links between the psychosocial factors and development of gender dysphoria.
In conclusion, the cause of transgenderism remains very unclear and is in need of considerable further research.
3. Are Gender Reassignment Therapies Ethical?
In his US district court declaration, Randi Ettner, the chief psychologist at the Chicago Garden Centre, neatly summarised the four-part standard of care on offer to people suffering from gender dysphoria8:
- Changes in gender expression and role, consistent with one’s gender identity (also referred to as social role transition)
- Psychotherapy for purposes such as addressing the negative impact of stigma, alleviating internalised transphobia, enhancing social and peery support, improving body image etc.
- Hormone therapy either to delay puberty, or to feminise or masculinise the body
- Surgery to alter primary and/or secondary sex characteristics
In the interest of relative brevity, I am going to focus on the ethics of the final two interventions: hormone therapies and surgery.
Intervention in Childhood: Puberty Suppression
This is the therapy (available on the NHS via specialist clinics), whereby pre-pubescent transgender children can take hormone blockers (GnRH analogues) that prevent the development of secondary sexual characteristics. This is in order to allow the child time to develop or fully assess their gender identity.
However, I believe that there are significant ethical concerns over puberty suppressive therapies. Firstly, there is strong evidence that most childhood dysphoria resolves before adolescence. The DSM-5 offers a range for persistence of dysphoria into adulthood at 2.2-30% in biological males, and 12-50% in biological females. These ranges are broad, but do show that the majority of case of childhood gender dysphoria resolve (without hormonal or surgical intervention) prior to adulthood.
In addition, there are concerns over the safety of puberty suppression. The NHS website states categorically that: “The effects of treatment with GnRH analogues are considered to be fully reversible, so treatment can usually be stopped at any time”9
However, there is little data to back this up. In a comprehensive review article into the medical consequences of puberty suppression, published in 2017, Paul Hruz (professor of paediatric endocrinology, Washington University), Lawrence Mayer (professor of biostatistics, Arizona Sate University), and Paul McHugh (professor of psychiatry, John Hopkins University) concluded:
“The claim that puberty-blocking treatments are fully reversible makes them appear less drastic, but this claim is not supported by scientific evidence. It remains unknown whether or not ordinary sex-typical puberty will resume following the suppression of puberty in patients with gender dysphoria. It is also unclear whether children would be able to develop normal reproductive functions if they were to withdraw from puberty suppression. It likewise remains unclear whether bone and muscle development will proceed normally for these children if they resume puberty as their biological sex. Furthermore, we do not fully understand the psychological consequences of using puberty suppression to treat young people with gender dysphoria…
In light of the many uncertainties and unknowns, it would be appropriate to describe the use of puberty-blocking treatments for gender dysphoria as experimental. And yet it is not being treated as such by the medical community… Physicians should be cautious about embracing experimental therapies in general, but especially those intended for children, and should particularly avoid any experimental therapy that has virtually no scientific evidence of effectiveness or safety.”10
In light of the natural desistence rates of childhood dysphoria, and the absence of clinical evidence for the effectiveness or safety of puberty suppression, I am uneasy about administering or advocating for puberty suppression in children.
Interventions in Adulthood: Masculinising/Feminising Hormones and Reassignment Surgery
In 2011, the World Professional Association for Transgender Health (WPATH) published its Standards of Care for the Health of Transsexual, Transgender and Gender Nonconforming People. In it, WPATH states “Feminising/ masculinising hormone therapy- the administration of exogenous endocrine agents to induce feminising or masculinising changes- is a medically necessary intervention for many transsexuals, transgender and gender nonconforming individuals with gender dysphoria.”11
However, in the same document, just 3 pages later, WPATH acknowledges that “no controlled clinical trials of any feminising/ masculinising hormone regime have been conducted to evaluate safety of efficacy in producing physical transition”12.
The evidence around outcomes following gender reassignment surgery is slightly more reassuring. The biggest study I am aware of is a 2011 cohort study of 324 individuals in Sweden which found a high rate of satisfaction with gender reassignment surgery (only 2.2% regret rate)13. However, the study also noted much higher rates of psychiatric conditions and suicide in individuals who had surgically transitioned, compared with the general population. This may of course be correlatory rather than causal, but was enough for the authors to conclude “Our findings suggest that sex reassignment, although alleviating gender dysphoria, may not suffice as treatment for transsexualism, and should inspire improved psychiatric and somatic care after sex reassignment for this patient group.”13
It is also significant to note that there is a high attrition rate among people seeking reassignment therapy; up to 50% of people who seek services will drop out before completion14. The reasons for this are unclear, and are probably a mix of frustration with the services, cost and management of dysphoria through psychological avenues. This also likely confounds the data around satisfaction/ regret with surgical intervention.
Putting statistics aside for the moment, I do also believe that the anecdotal evidence from those who have transitioned should give us pause for thought before we, as clinicians, offer hormonal and or surgical interventions.
The transgender movement has been driven almost entirely by the moving testimonies of individuals who have found their sense of identity through gender transitioning, and now feel at peace with themselves. This is how Caitlyn Jenner described her life, two years on from her 2015 interview with Diane Sawyer, and having undergone complete reassignment surgery: “[I am] happy, peaceful- peace in my soul. All of that confusion has left me… I have never had a doubt- I did the right thing”.15
Jenner’s experience is powerful and no doubt authentic. However, one group of people who almost never get media attention are individuals who have undergone gender reassignment and have come to regret their decision. I strongly suspect their silence comes, in part at least, from fear of persecution from the transgender activists. In his 2018 book When Harry Became Sally, Ryan Anderson dedicates an entire chapter to public articles and videos by so-called ‘de-transitioners’. Here are snippets from two of them.
Walt Heyer age c.70:
“I transitioned to female beginning in my late teens… But it wasn’t right for me; I feel only discontent now in the female role. I was told my transgender feelings were permanent, immutable physically deep-seated in my brain and could never change, and that the only way I would ever find peace was to become female. The problem is, I don’t have those feelings anymore. When I began seeing a psychologist… to help overcome some childhood trauma issues, my depression and anxiety began to wane, but so did my transgender feelings…. I can still resume my male puberty where it was interrupted and grow a full beard… My breasts are difficult to hide though. And saddest of all [due to previous orchidectomy], I can never have children, which I pray God will give me the strength to withstand that sadness.”16
Cari Stella, age 22:
“When you go to a therapist and tell them you have those kinds of feelings [of gender dysphoria], they don’t tell you that it’s okay to be butch… to not like men, to not like the way men treat you. They don’t tell you there are other women who feel like they don’t belong, that they don’t feel like they know how to be a woman. They don’t tell you any of that. They tell you about testosterone… I was put on hormones after 3 months of therapy at the age of 17… When I was transitioning, no one in the medical or psychological field ever tried to dissuade me, to offer other options, to do really anything to stop me besides tell me I should wait till I was 18… I want to ask you, how many other medical conditions are there where you can walk into the doctor’s office, tell them you have a certain condition, which has no objective test… and receive life-altering medications on your say-so?”17
One of the powerful recurring themes in the testimonials in Andersons’ book, is the deep anger de-transitioners feel towards their doctors, who failed to adequately explain the potential negative consequences of reassignment, and the possible alternatives to transitioning.
Concluding Thoughts on the Ethics of Gender Reassignment
The ethical landscape is complex, but here a couple of concluding thoughts.
I worry about the unknown consequences of puberty suppression in children, and believe we should be very cautious in our approach. And so until there is evidence for the safety of puberty suppression, I believe we should generally be taking a ‘watchful waiting’ to childhood dysphoria.
We also need more research into the consequences of hormonal therapies and reassignment surgery in adults. There is certainly evidence, both empirical and anecdotal, that these therapies can bring peace and sense of identity to dysphoric individuals. However, this is by no means universal. We cause harm as clinicians, when we fail to acknowledge that hormones/ surgery may not resolve individuals’ dysphoria, and that there are many potential serious complications both known and unknown.
4. What Does the Bible Say into These Questions?
I have intentionally left theology to last, mainly because I find it frustrating when Christians jump to firm, vocal beliefs about transgenderism with little understanding of the medical and social landscape. However, as a Christian, I believe the bible says some important things that need our consideration when we think about transgenderism.
In Genesis 1:27 we read:
So God created mankind in his own image,
in the image of God he created them;
male and female he created them.
In a recent lecture for the Zacharias Trust titled “How Can I Know my Gender”18, preacher-writer Sam Alberry highlights 3 relevant points from this verse.
- Embodied– it is part of our creation, not decided afterwards
- Foundational– spiritually intrinsic to our image bearing of God
- Binary– male and female
In other words, our maleness or femaleness, is more than just a physical characteristic that can be either accepted or changed to fit our desires; it is an intrinsic part of our creation, made to mysteriously and wonderfully mirror a small part of the nature of God. And thus our sex is not something that we should be altering with hormonal therapies or surgery.
In his lecture, Alberry then goes on this consider Ephesians 4:18, which reads: “They [sinful mankind] are darkened in their understanding and separated from the life of God because of the ignorance that is in them due to the hardening of their hearts.”
Alberry comments on this verse:
“[Eph 4:18]…is a very unflattering anthropology. But the bottom line is: none of us, not a single one of us, is qualified to determine our own identity. And whatever identity we do come up with for ourselves will not be a good fit. We just don’t have enough access to enough information to truly understand who we really are. And the only identity that could be a good fit would have to be an identity that comes from someone who knows us exhaustively and thoroughly.”
There are many worldly things that people put their identity in: success, appearance, affirmation from others, or sense of gender identity20. But the bible teaches that all of these things are deficient and ultimately vacuous. Instead, Christians are to find their identity in being a beloved, saved child of God21. As preacher Vaughan Roberts writes in his little book Transgender:
“We will always be insecure if our identity is based on something within us: our feelings, assertions or achievements. But this new identity in Christ that he offers us could not be more secure. We will often fail God, but our relationship with him remains unshakeable because it is founded not on anything we do but on what Christ has already done for us [in dying on the cross for our sins].”19
For people suffering from gender dysphoria, there may seem like only two available options- change their physical body to match their sense of gender identity, or suppress their inner sense of gender identity and accept their biological sex. However, I believe there is a third, better way. My desire is for people’s gender identity (cis or trans) to be eclipsed by an infinitely more secure and satisfying sense of identity that can be found in Christ alone.
- Jenner’s interview with Sawyer on ABC’s 20/20, 2015. Watch interview here
- Mark Yarhouse, Understanding Gender Dysphoria, 2015, IVP, p. 46-60
- Zhou, Hofman, Gooren and Swaab, A sex difference in the human brain and its relation to transsexuality, Nature, Nov 1995, vol 378, p68-70
- Chung, De Vries and Swaab, Sexual differentiation of the bed of nucleus of the stria terminalis in humans may extend into adulthood, The Journal of Neuroscience, February 2002, 22(3), p 1027-1003
- eg. Veale, Clarke and Lomax, Biological and psychosocial correlates of adult gender variant identities: a review, Personality and Individual Differences, 2009, p357-366
- eg. Meyer-Bahlburg, Gender Identity Disorder in Young Boys”, p 364
- eg. Zucker and Brandley, Gender identity and psychosexual disorders, The American Psychiatric Publishing Textbook of Child and Adolescent Psychiatry, 2004, p 813-835
- Declaration of Randi Ettner, US District Court, Middle District of North Carolina, Case 1:16-CV-236-TDS-JEP, p5. As quoted in: Ryan Anderson, When Harry Became Sally, 2018, p34
- Hruz, Mayer and McHugh, Growing Pains- Problems with Puberty Suppression in Treating Gender Dysphoria, Spring 2017, The New Atlantis, no 52, p3-36
- World Professional Association for Transgender Health, Standards of Care for the Health of Transsexual, Transgender and Gender Nonconforming People, 7th version, 2011, p33
- Ibid, p36
- Dhejne et al., Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden, PLoS One, 2011, vol 6 p.2
- Carroll, Gender dysphoria and transgender experiences, in Principles and Practice of Sex Therapy, 4th edn, 2007, p490
- Jenner’s interview with Sawyer on ABC News, April 2017. Watch interview here
- Walt Heyer, Regret Isn’t Rare: The Dangerous Lie of Sex Change Surgery’s Success, Public Discourse, 2017, 2016
- Cari Stella, Why I detransitioned and what I want medical providers to known youtube video, 2017. Watch video here
- Sam Alberry, How Can I Know My Gender?, Lecture for RZIM, Feb 2019. Watch video here
- Vaughan Roberts, Transgender, 2016, p58
- For more on the topic of “identity”, check out my sermon “Who am I?” on Psalm 8, watch here
- eg. John 1:12-13