One of the participants at the Jan. 9-11 Open Space gathering in
Winnipeg was a retired Canadian physician who is a member of a Mennonite
Brethren church.
This physician, who in keeping with the anonymous nature of Open Space
isn’t sharing his name, told me about research he had done into the topic of gender
and sexuality as it relates to transgender individuals—a group of people who
are often excluded from participation in church life.
He sent me a copy of his research, noting it was spurred by the 2021
report by the National Faith and Life Team (NFLT) of the Canadian Conference of
Mennonite Brethren Churches that dealt with LGBTQ+ people.
Titled Loving Well, the retired physician noted that, for him, the NFLT report suggested there is no “new truth”
that could persuade the denomination to change their collective mind that God
would not condone any gender identification other than “male and female.”
This view, the physician noted, “appears to be based entirely on their
interpretation of scripture without reference to new scientific ‘truths.’”
These new scientific truths, he said, show “it is the genes and/or the
appearance of the external genitalia that determine the sex of the individual”
but the “brain determines the gender, that is how one feels and identifies.
That these don’t always agree is understandable, given the complexity of factors
that interplay in human sexual development.”
The church, he went on to say, “has a rather unfortunate history of
fighting science with scripture and it has not ended well in the past. But this
time it is not about telescopes and models of the universe, this time we are
talking about people’s lives.”
Read his research below to learn how he arrived at that conclusion.
It is easy to ignore the latest cultural, scientific and medical issues,
such as gender diversity, when they don’t touch one personally.
I practiced Neurology for almost 40 years and never really encountered
gender diversity issues in the office, at least not that I was aware of.
Similarly, I have been a member of a Mennonite Brethren Church for about the
same length of time, and never really thought about the role that I or our
congregation might play in gender-affirmation.
But when it touched the lives of close friends, I decided to look into
it further. And when I read the 2021
report entitled “Loving Well,” prepared by the National Faith and Life
Team of the Canadian Conference, I felt compelled to respond.
The following is a summary of what I learned and the implications I feel
it should have for us as Christians. It is not by any means a comprehensive
review of the subject nor is it intended to replace information or advice from
professionals in the field.
My search began with a review of the biology of sex determination. This
starts in the womb and is based on genetic and hormonal factors.
The traditional view is that two X chromosomes determine a female and
one X and one Y, a male. This genetic code establishes the secretion of
estrogen in the female and testosterone in the male, which are primarily
responsible for the development of the external and internal genitalia. Some
estrogen is also present in males and some testosterone in females, but this
plays a lesser role.
Providing all of this goes as expected, the doctor in the delivery room
announces, “it’s a boy!” or “it’s a girl!” This “announcement” will influence
the rest of the child’s life.
What could possibly go wrong? Well, it turns out that sex determination
is a lot more complicated!
There are a number of known genetic abnormalities that can result in
difficulty in determining a child’s sex. One of these is a rare genetic
condition known as Androgen Insensitivity Syndrome. In order for the cells in
the developing male (XY) fetus to respond properly to androgens, of which
testosterone is the main one, they need the appropriate receptors.
In this condition, the androgen receptors are either partially or
totally absent, resulting in a genetically determined male with varying degrees
of female characteristics. If the androgen receptors are completely absent, the
person looks like a female. When they are only partially absent, the person may
have ambiguous genitalia or other combinations of male and female
characteristics.
There are other genetic conditions that could result in similar types of
confusion, such as Kleinfelter’s Syndrome (XXY) and Turner’s Syndrome (XO). The
incidence of all of these genetic abnormalities together is about 1.7%, the
same incidence as people with red hair.
The development of the brain is also influenced by both testosterone and
estrogen. This is likely responsible for at least some of the reported
differences between male and female brains. Which sex does the trans brain
resemble, the birth determined sex or their experienced sex?
This was addressed in a recent article in the Archives of Sexual
Behavior (2021). In this article the authors report their systematic review of
39 MRI studies that focused on gender identity and the brain. The results
indicated that some features of the trans brain were more like that of their
experienced sex but the majority were more like their birth determined sex.
They concluded that “conflicting results contributed to the difficulty
of identifying specific brain features which consistently differ between
cisgender and transgender groups,” and that more and larger studies are needed.
One of the more interesting of these MRI studies relates to the insula,
a small, virtually hidden, region of the brain. It is responsible for autonomic
control (sweating, heart rate, etc.) as well as body image and self awareness.
The study included 20 cisgender women, 20 cisgender men, and 40 transgender
women, half of whom had used hormones and half who hadn’t.
The data was inconclusive, but it did suggest that the size of the
insula was reduced in transgender women compared to cisgender women and
cisgender men. The potential significance of this was summed up by Dr. G.
Busatto, one of the researchers: “It would be simplistic to make a direct link
with transgender, but the detection of a difference in the insula is relevant
since trans people have many issues relating to their perception of their own
body because they don’t identify with the sex assigned at birth.”
The medical profession first began using hormone medication and surgery
to align a person’s physical sex characteristics with their gender identity in
the early 1900s. Gender-affirming care for adolescents started to be made
available in the 1990s, initially in the Netherlands.
One of the first clinical studies on treatment efficacy was at Johns
Hopkins University in 1979. It was a retrospective study on outcomes years
after treatment, of patient’s occupational, marital, educational and
domiciliary stability.
Unfortunately, the data pointed to worse outcomes for those treated than
those not treated and the gender-affirming treatment program was temporarily
closed. This, however, was before any guidelines for treatment were in place.
Subsequent studies repeated over the following years have shown that over 80%
felt they were better off.
The World Professional Association for Transgender Health has published
a document entitled “Standards of Care for the Health of Transsexual,
Transgender, and Gender- Nonconforming People.” This was recently updated in September
2022.
Their stated goal “is to provide clinical guidance for health
professionals to assist transsexual, transgender, and gender-nonconforming
people with safe and effective pathways to achieving lasting personal comfort
with their gendered selves, in order to maximize their overall health,
psychological well-being, and self-fulfillment. This assistance may include
primary care, gynecologic and urologic care, reproductive options, voice and
communication therapy, mental health services (e.g., assessment, counseling,
psychotherapy), and hormonal and surgical treatments.”
The guidelines continue to evolve through an ongoing extensive
peer-reviewed process that includes literature searches and expert input
followed by ongoing discussions within various associations. They emphasize
that treatment must still be individualized for each patient and adapted to
different regions and cultures.
The American Academy of Pediatrics has produced similar practice
guidelines on gender affirming care in adolescents, which, according to the
president, Dr. M. Szilagyi, “promotes following a holistic, collaborative,
compassionate approach to care with no end goal or agenda … and that there is
strong consensus among the most prominent medical organizations worldwide that
evidence-based, gender-affirming care for transgender children and adolescents
is medically necessary and appropriate."
One of the most significant issues in transgender health is gender
dysphoria, defined by the Mayo Clinic as “a feeling of discomfort or distress
that might occur in people whose gender identity differs from that assigned at
birth or sex related physical characteristics.”
The American Psychiatric Association has included gender dysphoria in
their recent Diagnostic and Statistical Manual (DSM 5). The APA emphasizes the
importance of this, citing that “multiple studies indicate that among
transgender nonbinary youth in the U.S., over 50% have seriously considered
suicide, which is significantly higher than the 3% to 5% of the general
population. It's been found that if transgender children start on the
appropriate gender affirming hormone, this figure drops dramatically.”
Gender dysphoria is not to be confused with gender nonconformity, which
refers to “the extent to which a person’s gender identity, role, or expression
differs from the cultural norms prescribed for people of a particular sex but
does not result in distress.”
This distinction emphasizes that gender nonconformity itself is not a
disease and does not always result in gender dysphoria.
It has been shown that gender identity conversion efforts, that is
psychological interventions that attempt to change one’s gender identity from
transgender to cisgender, are associated with adverse mental health outcomes in
adulthood.
An article published in Jama Psychiatry in January 2020 entitled,
“Association Between Recalled Exposure to Gender Identity Conversion Efforts
and Psychological Distress and Suicide Attempts Among Transgender Adults,”
reported a survey of over 27, 000 transgender adults. Twenty percent of those
surveyed recalled gender identity conversion efforts before age 10 years. They
were found to be four times more likely to attempt suicide during their
lifetime than those who had not been exposed.
One shortcoming of these clinical studies is that they have been
primarily retrospective, which means evaluating the outcome of a treatment
after it has been initiated, leaving room for the influence of treatment bias.
The few prospective studies that have followed patients from the time of
treatment have had small numbers.
Another criticism is that the studies have not been randomized or
placebo controlled, which is considered the “gold standard” in medical trials.
However, to randomly assign one group of patients to “no treatment” would be
just as unethical as the tobacco industry demanding a randomized placebo
controlled trial which would relegate one group to long term smoking, before
conceding that smoking was harmful.
Finally, likely one of the main reasons that many of the studies have
yielded results which are equivocal and difficult to interpret is that the
trans experience is very personal and variable and the issue of gender
diversity is very complex.
It is important to emphasize that gender-affirming care involves more
than just the medical profession. Several recent publications have shown that
transgender children who are supported in their identities and allowed to
socially transition have developmentally normal rates of anxiety, depression
and self-worth.
In contrast, transgender individuals whose families do not support their
transgender identities are 20% more likely to attempt suicide.
In conclusion, it is the genes and/or the
appearance of the external genitalia that determine the sex of the individual.
The brain determines the gender, that is how one feels and identifies. That
these don’t always agree is understandable, given the complexity of factors
that interplay in human sexual development.
Some preliminary scientific work points to a structural and
physiological basis for this gender identity discrepancy. Consensus within the
medical community is overwhelmingly in favor of accepting gender diversity as a
reality and providing appropriate gender-affirming care. This has resulted in
dramatically improved clinical outcomes in this group of patients.
The report prepared by the Board of Faith and
Life concludes that they have found no “new truth” that could persuade the
Canadian Conference leadership to change their collective mind that God would
not condone any gender identification other than “male and female.”
This view appears to be
based entirely on their interpretation of scripture without reference to new
scientific “truths.” The Church has a rather unfortunate history of fighting
science with scripture and it has not ended well in the past. But this time it
is not about telescopes and models of the universe, this time we are talking
about people’s lives.
References:
“Gender Dysphoria: A Review Investigating the Relationship Between
Genetic Influences and Brain Development” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7415463/
“Androgen Receptor Structure, Function and Biology: From Bench to
Bedside” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4810760/
“Brain Sex Differences Related to Gender Identity Development: Genes or
Hormones?”https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7139786/
“Is There Something Unique about the Transgender Brain?” https://www.scientificamerican.com/article/is-there-something-unique-about-the-transgender-brain/
“A Small Part of the Brain, and Its Profound Effects” https://www.nytimes.com/2007/02/06/health/psychology/06brain.html
“Structural Brain Differences for Transgender People” https://psychcentral.com/news/2018/03/16/structural-brain-differences-for-transgender-people#1
“Gender Dysphoria: Time for a New Model Based on Psychobiology” https://consultqd.clevelandclinic.org/gender-dysphoria-time-for-a-new-model-based-on-psychobiology/#menu
“Insula” https://www.kenhub.com/en/library/anatomy/insula-en
“Grey and white matter volumes either in treatment-naïve or
hormone-treated transgender women: a voxel-based morphometry study” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5768734/
“The largest study involving transgender people is providing long-sought
insights about their health”https://www.nature.com/articles/d41586-019-01237-z
“AMA to states: Stop interfering in health care of transgender children” https://www.ama-assn.org/press-center/press-releases/ama-states-stop-interfering-health-care-transgender-children
“Gender Dysphoria” https://www.mayoclinic.org/diseases-conditions/gender-dysphoria/symptoms-causes/syc-20475255
“What is Gender Dysphoria?” https://www.psychiatry.org/patients-families/gender-dysphoria/what-is-gender-dysphoria
“Association Between Recalled Exposure to Gender Identity Conversion
Efforts and Psychological Distress and Suicide Attempts Among Transgender
Adults” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6739904/
“Group Blog From the Gender Equity Working Group: How the LGBTQI Section
of the American Academy of Neurology Plans to Help the Transgender Patient Feel
Less Like a Fascinoma” https://blogs.neurology.org/ideas/group-blog-from-the-gender-equity-working-group-how-the-lgbtqi-section-of-the-american-academy-of-neurology-plans-to-help-the-transgender-patient-feel-less-like-a-fascinoma/
“Proud to Care for ALL Manitobans. For the first time in its
114-year history, Doctors Manitoba participated in the 2022 Winnipeg Pride
Parade this June.” https://doctorsmanitoba.ca/news-events/rounds
“Treating Transgender Individuals” https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2015/treating-transgendered-individuals
“The Search for the ‘Transgender Brain’ is Dangerous - and Dehumanizing” https://www.thedailybeast.com/the-search-for-the-transgender-brain-is-dangerousand-dehumanizing?ref=scroll
“Structural, Functional, and Metabolic Brain Differences as a Function
of Gender Identity or Sexual Orientation: A Systematic Review of the Human
Neuroimaging Literature” https://link.springer.com/content/pdf/10.1007/s10508-021-02005-9.pdf?pdf=button
“Standards of Care for the Health of Transgender and Gender Diverse
People, Version 8” https://www.tandfonline.com/doi/epdf/10.1080/26895269.2022.2100644?needAccess=true&role=button&