Last Friday, a bill that would ban transgender athletes from competing in middle, high school, and college sports passed in the West Virginia legislature. At least 20 different state legislatures have introduced transgender athlete bans in 2021. While South Dakota’s governor Kristi Noem vetoed a proposed ban, Tennessee, Arkansas, and Mississippi have signed these changes into law.
Arkansas’ governor, Asa Hutchinson, did, however, veto legislation that would have banned gender confirming treatments or sex reassignment surgery for transgender youth under 18. That bill would have been the first in the country to ban this practice. Meanwhile, last Monday, GOP legislators in North Carolina introduced a bill that that would prevent doctors from performing sex reassignment surgery for transgender people under the age of 21.
This flurry of state bills—a month ago LGBT advocacy group Human Rights Campaign had counted more than 80—has once again provoked impassioned fighting, much of it centered around children. It’s led to questions of fairness in youth sports, if adolescent judgement and diagnosis should be trusted, and what role and what say parents should have in how their children express their gender.
Mark Yarhouse is a pyschology professor at Wheaton College and the director of the Sexual and Gender Identity Institute. His books include Understanding Gender Dysphoria and most recently, Emerging Gender Identities. He joined global media manager Morgan Lee and editorial director Ted Olsen on this week’s episode of Quick to Listen.
What is the same and what has changed in the conversation around gender over the past five or six years?
Mark Yarhouse: The conversation around gender has become more pronounced and centered in cultural discussions.
You see an increase in the number of people who identify as transgender or what I refer to as emerging gender identities. There's a splintering of gender categories into different experiences, different language for describing people's experiences.
Things have become more polarized as well. You saw that with the reaction to legislation like the bathroom bill, and you see that now with the law passed in Alabama. 20 or more states have gender identity–change laws in place for minors to keep that from happening. There’s an increase on both sides of a divisive topic.
Mark Yarhouse: When I wrote my first book on understanding gender dysphoria, I was trying to introduce evangelical Christians to the concept of transgender experiences. Gender dysphoria is this experience that's distressing when a person's gender identity doesn't align with their biological sex.
When I talk about emerging gender identities, it's beyond that basic framework of transgender. Young people say that they’re gender-expansive, they’re gender-creative, they’re bi-gender, they’re pan-gender and the different identifiers go from there.
It helps us as Christians to be thoughtful in how we engage in a culture that's shifted so dramatically and where language has been shifting. You're interacting now with younger people for whom these are taken-for-granted realities and the generation that went before them had a limited scope of categories and language. There’s a real high likelihood of our misunderstanding and talking past one another.
Do the lessons about transgender issues from before map onto the emerging gender identities?
Mark Yarhouse: Some of the lessons learned will map onto that. It's challenging to know exactly how to, as Christians, enter into this conversation because we have had norms around sexuality and gender that we want to be able to articulate.
But sometimes when we articulate those norms, we can do it in ways that seem to cast doubt on the experience of other people around us, who don't use those same norms as anchor points that we do. It ends up becoming more of a risk of speaking past each other or being entrenched in not understanding.
You can both teach norms around sexuality and gender and recognize that there are exceptions to those that are likely the result of a fallen world and the challenges that people face in that space. There are also clinical differences and issues from a classic transgender presentation and some of the emerging gender identities.
To seek common ground, is it helpful to talk about how we also have dysphoria or don’t conform to cultural or biblical notions of what it means to be male or female?
Mark Yarhouse: There are an upside and a downside to that approach. Christians would hold that we have so much in common as we bear the image of God and we should start there. People are beloved by God. God wants a relationship with people. There’s so much in that sense as a starting point for shared human experience.
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But if you overplay that, you look past how some people's experience is so far on the margins that you might not fully appreciate the challenges that they're facing, particularly when it is dysphoria, a painful experience that you've never experienced.
There are also people saying that this is willful disobedience on your part. We're not speaking the same terms here about people's experiences.
How do you define gender dysphoria? Is the term interchangeable with the idea of transgenderism?
Mark Yarhouse: Gender dysphoria is the discomfort or distress that's associated with the lack of concordance between someone's biological sex, usually thought of in terms of chromosomes, genitalia and gonads, and the person's gender identity, their experience as a man or a woman or a different gender identity than that.
When that's distressing to them, it's dysphoria versus euphoria, a positive emotional state. It's a negative emotional state. I don't think of that as synonymous with transgender but many people who would identify as transgender would report gender dysphoria. It can vary in severity from mild to severe, and it can ebb and flow in severity in a person's life.
Historically, gender dysphoria was thought of as having an early onset. A boy or a girl is aware of their gender between ages two and four, developmentally. They're aware that they're a boy or a girl, or they're going to express a different experience than that.
What we've seen in the last six years has been a remarkable increase in the number of cases that we would call late-onset. That means at or after puberty, the person is reporting dysphoria that they didn't appear to have much evidence of, if at all, in childhood.
That's what's concerning to some mental health professionals and others. There’s not been a satisfying explanation that accounts for that increase.
Is it true that, before the last five or six years, people that were saying “I’m trans” most likely started feeling those feelings well before puberty?
Mark Yarhouse: Most of the cases had been what we would call early onset. Parents would wonder if their child was going through a phase. They would probably go to a specialty clinic when that child turned six or seven, maybe when they were going to preschool or kindergarten, when the comparison would be their peer group, rather than at home with their family.
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Historically, that would be the more typical presentation. It was more often biological males rather than females, at about a four- or five-to-one ratio that would be referred to these specialty clinics. That was probably the result of having a narrower box for what a boy can be like.
If they're outside of that expectation, then it raises more flags for parents. Whereas girls can have a little more latitude in how they present; and if they're gender atypical in some ways, you have positive language for that. They could be tomboyish and no one's going to be particularly concerned.
That probably accounted for that ratio, but now you're seeing quite a flip. Now we're seeing not just the late-onset cases at a higher rate, but also seeing it among biological females at a higher rate than you do males. We don't understand what's going on with that switch.
How do you distinguish between someone who expresses themselves outside the cultural understanding of masculinity or femininity, versus someone who feels uncomfortable being a particular gender?
Mark Yarhouse: When you meet with somebody to make a diagnosis of gender dysphoria, you rule out that they're within the range of what a boy or girl, or a man or a woman, would be like. They maybe have different characteristics, different presentations, different ways different interests, and so forth that are gender atypical. They don't fit into maybe stereotypes, but they're not gender dysphoric.
So how do you make that distinction? Several things go into that. You can have a conversation with an adult and they’re telling you. It's harder when you're trying to make that determination with a child who might not be able to pull all that together. But there are certain criteria that you follow around what they're able to say about their gender identity.
It's usually their response to primary and secondary sex characteristics. It's the desire for the sex characteristics of the other gender. These things aren't for a few weeks or a few months; it's over time and it's significant. It's significant in their body image and how they experience and see themselves. It's distressing to them.
What advice would you give to adults who have recently learned that a young person in their life is trans?
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Mark Yarhouse: Christians typically have this skill set. We are used to applying it to other groups of people whose individual characteristics are different than our own. For example, we don't seem to have difficulty relating to our agnostic neighbors, even though their characteristics around their religious identity are different than ours.
We have a sense of how to relate to that person who's different in terms of racial or cultural background. When people's characteristics vary from ours, we can relate to them, talk with them, recognize God's love for them, value them as a person, to encourage them to bring all of their experiences into the relationship that we're forming with them as an acquaintance and maybe a friend.
You use the same skill set here. It's doesn't have to be more difficult than that.
I don't normally speak into the lives of adolescents around me unless I have a relationship with them and I'm invited into that space. It would run a significant risk of me overstepping the nature of the relationship I have with them, and then likely speaking past them. Then what they may know about me is that I'm a Christian who’s now a witness to them. I have this top-down approach where I'm telling them that they're at-risk or they're doing something wrong.
I would probably take the position more with an adolescent than I do as a neighbor, as a family friend, or something like that. To listen more about what their experience has been like, remember that they're navigating at their age.
Their generation has a lot more categories for language around categories and linguistic constructs around gender and sexuality than my generation did. They're probably deeply shaped by what's been made available to them and they're interacting with those categories and they're making sense to them, or they might not make sense to me.
I might have a reaction to that, but it would be better to understand how the language functions for an adolescent rather than begin with the place that they're wrong or that they need to be corrected. That kind of mutational strategy does not work with adolescents period. It doesn’t work in this conversation because our connection to their language has been so different and they've been exposed to so many different categories.
How do you counsel people on the basic questions of name and identity?
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Mark Yarhouse: If a person is able to live in a way that reflects their birth sex, it’s going to be less complicated.
There are so many layers of complexity. Some people are in this place where they're considering a social transition or a partial transition, and they're trying on different names and pronouns.
If the person's trying to do that because they've been suffering from gender dysphoria and it's been distressing to them, and they've used other strategies to manage that (like the clothing they wear, the way they keep their hair, and these things have taken the edge off that dysphoria and been helpful to them), but it's sufficiently distressing that they think that using pronouns that they would prefer might be helpful to them, then I'd like to understand what's behind the request and how it's functioning for them.
That's not an uncommon strategy that people use. They try to use these strategies usually in a trial-and-error way and in a stepwise fashion. They can always reverse and go back to their original pronouns.
They can always do that; they're trying to figure this out. I don't want to be overly reactive to that. I want to meet them where they are. I want to have a sustained relationship with them. I err on the side of hospitality towards somebody to be in a relationship with them rather than do things on the front end that would sever the tie that they might otherwise want to have with me.
What advice do you have for parents as they try to understand where their child is coming from?
Mark Yarhouse: When you have early onset, parents are not that surprised when a child says to them, “I'm transgender,” or “I experience my gender identity differently than most people do,” or however they frame it. Parents knew something was going on. They just didn't have language for it. But when you have late-onset cases, it is blindsiding. Parents feel like their world has been rocked and there's no reference point for what their teenager is saying. There's little or no history to understand it.
There has been some concern that there might be teens who have other issues going on in their life and they're finding a sense of identity and community in something that has such social salience today. It's moved to the center of some of the cultural discourse around sexuality and gender, where some time ago, being gay had occupied that space.
The transgender conversation has moved into that space culturally and maybe a generation ago, a young person might've landed in a different area and explored different aspects of themselves. But today this has the kind of salience that might be appealing to some people where they might not have gender dysphoria.
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There may be other things going on and they're finding something in this space. I want to be careful when I say that because I don't think that's most of what I'm seeing in my clinic. Some people have been trying to research that as a possible phenomenon.
Is that something that is trending among adolescents and we should be cautious about? I want parents to be wise and discerning to check things out with a provider, someone who has expertise in this area and to realize there could be multiple things going on here and it would take discernment and time to figure out what's going on.
Are there important ways that we should differentiate between dysphoria and transgender issues, versus same-sex attraction issues?
Mark Yarhouse: They are different experiences. When someone describes themselves as gay, they're talking about their attraction towards the same sex and their orientation towards the same sex. When someone says that they're transgender, they're talking about their experience of their gender identity as a man or a woman or a different gender identity than that.
Gender identity doesn't have to do with who you're physically, emotionally, or sexually attracted to. A lot of times when people are wrestling with dysphoria, they're often being asked about their sexual orientation. That's a confusing topic for some people.
They're not sure what they could even say about that. They're trying to figure out what's going on around gender. Sometimes Christians are more preoccupied with sexual behavior. I don't think that's where a lot of people are when they're figuring out gender. That's a different thing for them. Distinguishing that is helpful.
Some Christians see that Scripture speaks more to the question around sexual behavior than it does to gender identity. That complicates this conversation more. It's not that Scripture doesn't say anything about gender, but it doesn't certain passages that stand out around sexual behavior. It's not quite as clear if you're looking for direct scriptural passages.
What effect do you expect banning surgery for young people to have?
Mark Yarhouse: There are several things that minors might consider, like whether to block going through puberty. That's right at the beginning of the development of puberty. Then young people might consider using cross-sex hormones at some point, maybe a year or two later. If they did the puberty-blocking intervention, then that becomes a consideration. Some of the legislation may be looking at that. There are surgical procedures as well.
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On both sides of this debate, people have young people's best interests at heart. They're both trying to address vulnerable young people that they're concerned about, but they're landing diametrically in places to express their concern. Those who are saying we shouldn't allow these types of procedures are saying young people don’t have the capacity to make these kinds of decisions, to understand the consequences of these decisions, and what that could mean for them five or 10 years out.
Other people believe that young people are at great risk and that these are the kinds of things that medical and psychiatric providers think should be on the table and considered for a young person. They can make that decision.
What are some of the consequences that people proposing these bans are concerned about? To what extent are they valid or exaggerated?
Mark Yarhouse: With the use of cross-sex hormones, this would be a lifelong regimen that a young person would have to take to have the clinical effects of using the other hormones of the other sex. If you stop taking the hormone, you stop having that clinical benefit.
We don't have the kind of long-term research on the effects of an adolescent using cross-sex hormones over 30 years. The greatest risk would be the risk for sterility.
Another topic that people are concerned about is that a young person at 16 or 17 doesn’t understand what that would mean in 10 years. Do they understand the risks that they're taking there?
I'm not a fan of legislating around these complex clinical issues on either side. Once you move towards legislation on either side of these complex issues, ultimately, it ends up not being nimble enough to respond to the needs of the next person in front of you. I'd love for those needs to be met more by the mental health profession and the people who are working with them.
Those that regulate the mental health professions, that's where typically complaints would be adjudicated. It would be through the people who were licensing the providers to provide services rather than through legislation that creates a statement that's applied to everybody across the board. That doesn't end up being as flexible on members as we would.
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Have you seen any examples of school districts figuring out how to have trans girls and women play in youth or collegiate sports without resorting to laws?
Mark Yarhouse: We need more time to research how to measure advantage and what that looks like. When you develop a policy like the NCAA has tried to, looking at the length of time to be on hormones, there's good intention to try to figure that out. What gives someone a competitive advantage? How do you safeguard that without excluding people from being able to compete when this is what they have trained to do?
They're good at this, and you want to allow them to do this. There have been controversies at every level of competition; this is not going to be resolved quickly. There hasn't been enough work done on clarifying what those standards would need to be across the board. Maybe they need to be applied more on a case-by-case basis than having one length of time that's applied to everybody. I wonder if it's more complicated than it's been made out to be.
How should we understand stories of people who have transitioned, then transitioned back? What kind of attention should they get?
Mark Yarhouse: Sometimes it's referred to as de-transitioning. I haven't seen a very well-designed study that would show us how common that is. In the Netherlands, they recently published a report on 30 years of people using different interventions, including surgical procedures.
The rate of regret continues to be low. I don't think that you're seeing a dramatic rise in regret that would typically correspond with de-transitioning. You could have regrets about surgery and elect not to be transitioned. We need to study that more to see how common that is, but based on the rates of regret that were published more recently, I don't see a rise in that.
I am concerned that we could see a rise in that for the reasons that I've talked about: atypical presentations, late onset, the gender ratio flip towards more cases of female adolescents with later onset. Where will they be in five or 10 years? We don't know yet.
Most actually don't make medical transitions at this point, but if they were to, would we see a rise in regret? I'd be curious.
How do you recommend we pray for people who are experiencing gender dysphoria?
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Mark Yarhouse: We pray for God to continue, if He's already been speaking to them, to continue to speak to them; to speak to me, to guide me, to help me know best how to see the person, to love this person, that they would know that they are loved by God. For me and them to have wisdom and discernment moving forward. For wisdom and discernment on how I relate to them as someone that God cares deeply about.
Those are the types of prayers that I pray. I also provide ministry outside of my role as a psychologist. That's been helpful to me in walking with people. I mentioned that most people don't make a medical transition at this point. I think in the last transgender survey, about 44% of something like 26,000 transgender persons had indicated that they were using hormone treatment and only about 25% had used any type of gender confirmation surgery.
That's been a helpful conversation to have in the back of my mind.
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