Gender Dysphoria and Public Health

President Biden's nomination of Dr. Rachel Levine to the position of Assistant Secretary of Health has brought the discussion of transgenderism to our attention once more. If confirmed, Dr. Levine will become the first openly transgender official confirmed by the U.S. Senate. Levine reportedly transitioned in 2013, having undergone sex reassignment surgery and hormonal treatment.

By itself, this does not alarm me. The fact that a person is transgender does not mean they are incapable of performing admirably in most careers. Neither am I questioning, in general terms, the medical training, experience, or competence of Dr. Levine. For example, I will gladly concede the point that Dr. Levine has demonstrated acumen in handling Pennsylvania's response to COVID-19. Christians must do better in acknowledging the full humanity and common personhood of all people, including those within the transgender community.

The concern I hope to fairly articulate today is more specific. My concern is argued as follows:

1. Gender Dysphoria is a universally recognized psychological condition. Persons with gender dysphoria experience real heartache and distress in need of healing.

2. History and science have taught us that treating a psychological condition with a risky, side-effect-laden surgical or chemical approach is detrimental to human health. It is just bad public policy.

3. Even setting aside the risk, sex-reassignment surgery does not accomplish its goals. In many ways, sex-reassignment surgery makes false promises.

4. The Christian response to the pain of gender dysphoria should be to offer help, compassion, and healing. Sex-reassignment surgery and related procedures accomplish none of these goals.

Gender Dysphoria Is a Psychological Condition

For many years, the transgender community and those in the helping-professions have struggled to find the correct term to describe the psychological condition involved. What term should be used to describe the discomfort of feeling like your experienced identity does not match your body?

The standard text for mental health professionals is the Diagnostic and Statistical Manual of Mental Disorders (DSM). Until 2013, the DSM-IV stated that a person experiencing distress in their experience of gender as opposed to their apparent biological gender had a gender identity disorder. A mental disorder was defined as "a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significant risk of suffering death, pain, disability, or an important loss of freedom."

However, it has been argued more recently that the term "disorder" created discriminatory attitudes. While it is universally agreed that the experience of gender-related distress needs to be resolved, the question remained as to whether labeling this distress as a disorder made a moral judgment and inadvertently worsened the distress.

The DSM-5 was revised to use the term "Gender Dysphoria." The reasoning was not based on any scientific data but out of concern "that continued labeling of expressions of gender as pathological is discriminatory and perpetuates stigma, causing harm to transgender individuals." According to the Mayo Clinic's resources, "The term gender dysphoria focuses on one's discomfort as the problem, rather than identity."

Regardless of the shift in terminology, the fact remains that gender dysphoria is still defined as "psychological distress that results from an incongruence between one’s sex assigned at birth and one’s gender identity." (See also Yarhouse's excellent book for a discussion of this terminology.) In sum, the professional community admits that the distress experienced by a transgender person is primarily a psychological condition.

From a Christian point of view, my heart aches for anyone in distress. I have struggled with anxiety in my life. My struggle does not parallel the depth of the turmoil in the soul of one experiencing gender dysphoria, but I do know what it means to feel that my cognitive self – mind, behavior, and emotion – was not as it should be. My point in this article is not about shaming people with psychological distress. My point is that before we can help, we need to characterize the issue correctly.

Gender dysphoria is a psychological condition, and in the general case, psychological conditions warrant psychological treatments.

Medical Responses to Psychological Conditions

It is not uncommon to use medical – either chemical or even surgical – treatments in response to psychological conditions. People suffering from depression are often prescribed medications to assist in their mental health. For example, I take a daily prescription to help manage my anxiety, and it has made all the difference in my life.

Surgical treatments are more extreme but not unheard of. When we think of surgical treatments for psychological conditions, the first things that may come to mind are the horror stories of maltreatment in the 19th and early 20th centuries. In 1927, Julius Wagner-Jauregg became the first psychiatrist to win the Nobel Prize. His work included infecting his patients with malaria to induce fever to cure their mental condition. His attempts led others to experiment with insulin therapy and shock treatment. As recently as 1949, Antonio Moniz was awarded the Nobel Prize for the invention of the lobotomy as a medical approach to schizophrenia. Since the development of alternative pharmaceutical drugs in the 1960s, such barbarism has fallen out of favor.

In light of this dark history, reason suggests that the first line of defense for a psychological condition would be psychological rather than surgical or even chemical. It is an approach that keeps with the spirit of the oath to “do no harm.” For example, we can look to other cases where a person's perception of their identity or condition differs from observable, biological reality. In the case of anorexia, the person feels distressed because they perceive themselves to be overweight regardless of their measurable body mass. It would be unethical for a doctor to recommend a hazardous treatment of liposuction rather than mental care. However, in the case of gender dysphoria, the patient is often treated differently.

The primary danger of surgical solutions for psychological distress is that psychological states sometimes change. Surgery is a permanent response to a possibly transitory psychological circumstance. According to reports cited by Dr. Paul McHugh of Johns Hopkins, "When children who reported transgender feelings were tracked without medical or surgical treatment at both Vanderbilt University and London's Portman Clinic, 70%-80% of them spontaneously lost those feelings."

A recent study issued by the National Center for Transgender Equality is stated, "Eight percent (8%) of respondents reported having de-transitioned at some point. Most of those who de-transitioned did so only temporarily: 62% of those who had de-transitioned reported that they were currently living full time in a gender different from the gender they were thought to be at birth." Admittedly, 8% is not a high number, but for people in that 8%, they have limited options because of the surgery’s semi-permanence.

Sex-Reassignment Surgery Does Not Accomplish Its Goals

Moreover, sex-reassignment surgery does not in fact change a person’s gender, a point on which most of the transgender community will agree. A transgender person already believes the internal gender experience is different from that represented in the biological body. In other words, the surgery does not change what they believe themselves to be but instead attempts to align the body with the identity experienced within. A person whose birth gender is male may feel that their internally experienced gender is female. In that case, sex-reassignment does not change their gender. The person identifies as a female before and after the surgery. In terms of sexual identity, nothing has changed.

Neither is it clear that sex-reassignment surgery changes a person’s biological sex. In the typical case, biological sex is indicated by a person’s chromosomes (either XX or XY). Of course there are notable exceptions, of course, but the Intersex Society of North America states that only 0.06% of all people have neither XX nor XY chromosomes at birth. Another 0.1% have Klinefelter syndrome, being born with XXY chromosomes. These cases do not change the statistical fact that biological sex is identified by chromosome pairs in over 99.5% of the human population. Sex-reassignment surgery does not alter chromosome pairs in any way, meaning that one of the primary biological sex identifiers remains unchanged before and after surgery. Thus, the reasonable question, did this surgery change the person’s biological sex?

From another perspective, I would even question whether the removal or addition of specific sexual organs changes sex (or gender). Here again, I’ll speak to this from personal experience. In May of 2020, my wife was diagnosed with Triple Negative Breast Cancer. The treatment plan was aggressive and included a bilateral mastectomy in the Fall of 2020, as it often does for women with this diagnosis. Some women choose to have a cosmetic reconstruction of their breasts, and others do not. In either case, is the biological sex of the person any different after a bilateral mastectomy? I think most women would say it is not, despite the removal of one feature typically associated with biological sex. The same could be said for a woman having a hysterectomy to remove the uterus. I think we would say to these women, “Your gender is more than any one or two or three sexual organs. It is deeper and more meaningful than that.” For me, it raises serious questions about whether surgery even has the capability of changing biological sex.

Sex-reassignment surgery does not fully resolve the emotional distress that prompted the surgery. As Dr. Paul McHugh reports:

A 2011 study at the Karolinska Institute in Sweden produced the most illuminating results yet regarding the transgendered, evidence that should give advocates pause. The long-term study—up to 30 years—followed 324 people who had sex-reassignment surgery. The study revealed that beginning about 10 years after having the surgery, the transgendered began to experience increasing mental difficulties. Most shockingly, their suicide mortality rose almost 20-fold above the comparable nontransgender population. This disturbing result has as yet no explanation but probably reflects the growing sense of isolation reported by the aging transgendered after surgery. The high suicide rate certainly challenges the surgery prescription.

Likewise, in a recent study issued by the National Center for Transgender Equality, "Thirty-nine percent (39%) of respondents reported currently experiencing serious psychological distress, a rate nearly eight times higher than in the U.S. population (5%).”

I cannot help but feel grief for a person who has suffered under emotional and psychological distress and risked a potentially dangerous surgical solution, only to find that the underlying psychological issues had not been resolved. Why does surgery fail to resolve gender dysphoria? Because, as stated above, psychological concerns most often warrant psychological responses.

The Tragedy of “No Better But Worse”

As a Christian, I am committed to a definition of gender rooted in the creation account of Genesis 1:26-27. I believe a person with Gender Dysphoria needs healing, but not the sort provided by sexual-reassignment surgery or hormonal treatments. I believe that false stereotypes of gender in our culture and the systemic result of sin at work in humanity generally and individually have produced more negative results than we might ever have dreamed possible. I believe my sins contribute to this, and only God can make things better for any of us.

However, as you hopefully noticed above, the concern expressed here is not built on any particular biblical foundation or religious premise.

If we would accept the morally neutral premise that psychological distress warrants a primarily psychological response, then most medical responses to Gender Dysphoria would need to cease.

If we accepted the standard psychiatric assumption that a disagreement between the mind and the body is resolved by healing the mind,, we would not wish to normalize the medical responses currently under discussion.

If we would accept the medically essential commitment to first "do no harm," then sexual-reassignment surgery would become a prohibited treatment option due to its detrimental side-effects both to physical and mental health.

The Bible tells a tragic story of an unnamed woman who suffered from a serious condition. Mark recounts, “And there was a woman who had had a discharge of blood for twelve years, and who had suffered much under many physicians, and had spent all that she had, and was no better but rather grew worse” (Mark 5:25-26).

When I read that story, I think of all the charlatan faith-healers through the years who preyed on the sick in the guise of Christianity. It makes me angry to think about a person who sees another human hurting and offers a lie. What cruelty to offer a solution that cures nothing and potentially makes the situation worse!

I am afraid that surgical and chemical responses to gender dysphoria too often fall into this same category. They offer false promises to people already struggling with their identity.

As Christians, we need to be more sympathetic to the emotional distress at work in the life of a transgender person. But we also need to be truth-tellers, which includes recognizing that many of the popularized treatment options today produce harm rather than healing.

Ben Williams is the Preaching Minister at the Central Church of Christ in Ada, Oklahoma and a regular writer at So We Speak. Check out his books The Faith of John’s Gospel and Why We Stayed or follow him on Twitter, @Benpreachin.