An Approach to Transgender Issues

If you swim to rescue a drowning person, they may put you in a headlock and try to climb onto you in an effort to keep their head above water. You should not fight to break loose or compete for breaths. Rather, you should dive. They will release you to stay on the surface. You can then come up behind them, put a secure hold on them, and carry them to safety.

Transgender issues bring up a multitude of moral, religious, philosophical, medical, legal, and relational matters. A variety of materials including stories and use of the imagination may enable us to go below the surface of issues and thus get a good hold from another angle to help transgender people. Diving signifies humility rather than being combative toward struggling people who may feel their lives are at stake.

In a widely retold story, Rabbi Nachman of Breslov depicts a Prince who thought he was a turkey. He felt compelled to sit under the table without any clothes on, pulling at bits of bread and bones like a turkey. A Wise Man took off all his clothes, sat down under the table next to the king’s son, and also pulled at crumbs and bones. “I’m also a turkey,” said the Wise Man. The two of them sat there together for some time, until they were used to one another. The Wise Man-Turkey said to the king’s son, “Do you think a turkey can’t wear a shirt? You can wear a shirt and still be a turkey.” The two of them put on shirts. One by one they put on the rest of their clothes in the same way, and finally returned to the table. “You can be a turkey and sit up at the table.” This is how the Wise Man cured the Prince.1

One implication of this story is that God gives everyone a turkey self, a yetzer
ha-ra, not because God wants us to follow its demands, but to challenge us. Or, as C.S. Lewis wrote, every disability conceals a vocation—if only one can find it. But each of us is a child of the King—who represents God. Putting on clothes and sitting at the table symbolize connecting with God.

God’s Good Creation

In the beginning, God created the heavens and the earth. God ordered the world by separation and distinction. The binaries were not antagonistic to each other, but functioned harmoniously together. God created humans in his own image, male and female. It was very good.

Scripture tells me to love my neighbor as myself (Lev 19:18), but it does not tell me to love myself. That it is good and natural to love myself is a necessary presupposition of the Bible. Ephesians 5:28–29 counsels that husbands ought to love their wives as they do their own bodies, for no man hates his own flesh. It follows that a human self includes the physical body and the mind aware of it, receiving information about the outside world through it, and directing movement of that body. Scripture assumes the reality of other selves beyond my own self, and of the world outside myself. This is a foundation of natural law. Of course we have all experienced instances of misperceiving something with our senses. Yet we can receive reliable information and are designed to respond to our senses.

Philosophy grounded in both theology and the natural world helps for understanding sex and gender.2 Our bodies are not just something we use, but are part of our selves. Sex, being male or female, is manifested in the body and thus not private and subjective, but public and objective. There is a binary because human bodies are ordered toward producing one of two gametes which unite to form new life.

In the recent Catholic document, “Male and Female He Created Them: Towards a Path of Dialogue on the Question of Gender Theory in Education,” “gender” refers to the way the differences between the sexes are lived in each culture. In this sense, gender is public and objective, but culturally conditioned. This should not be confused with “gender identity,” which is one’s sense of one’s own gender. Gender ideology posits that gender is entirely separable from sex, and denies the gender binary. I prefer the Catholic document’s understanding of gender, and believe that clarifying disputed terms improves dialogue.

Gender Dysphoria and Other Dysphorias

Dysphoria is a state of feeling unwell, uneasy, or unhappy. The evaluation and treatment of gender dysphoria ought to be informed by approaches to the other dysphorias. People with gender dysphoria have higher than average rates of body integrity disorder, self-harm, eating disorders, and depression.3

Signals from injured regions of the body are perceived in the brain as pain. Sometimes a signal becomes self-reinforcing, generating pain long after an injury has healed. Sometimes a person feels pain in an amputated (phantom) limb. For example, one may feel the nails of a clenched fist digging into the palm of the hand one no longer has. Such pain can be relieved by gradual exercises of mentally unclenching the missing hand.4

Some people have a healthy limb but experience it as a foreign entity (body integrity identity disorder, or BIID). Their obsession may become so severe that they seek amputation of the limb, and intentionally mutilate the limb. Oliver Sacks tells of a neurological patient who woke up in bed to the horrible realization that someone else’s leg had been placed under the sheets in contact with him. Grasping it firmly with both hands, he threw it away. The next thing he knew he was on the floor.5 This story is distinguished from BIID, in which the person who desires amputation is considered to be sufficiently in touch with reality as to recognize that the limb is theirs. Then again, some pretend to be amputees.6 One theory sees BIID as a failure of mapping the body in the brain. The argument in favor of amputation is that it relieves suffering, lesser measures cannot, people with BIID are competent to consent to amputation, and their human dignity requires autonomy in the decision. The argument against is that psychiatric categories have a looping effect such that people use them to construct their identities, people with BIID lack sufficient autonomy to consent, and amputation does great physical harm, leading to lifelong costs borne by society.

Anorexia nervosa is a potentially life-threatening condition in which one starves oneself because of the perception that one is fat and that eating and the body are disgusting. Researchers note three ways that authenticity may operate. (1) The anorexic parts of me are powerful but inauthentic. (2) The anorexic parts of me are undesirable in some ways but are an authentic part of me. I must learn to live with them while minimizing damage from them. (3) The anorexic parts of me are authentically me and I do not want to treat or suppress them. This last way blocks recovery.7 In medical opinion, anorexia is not considered justification for weight loss surgery.

Dysphoria is often a symptom in major depression, the leading cause of disability worldwide. There is evidence that depression is increasing, and is a disease of modernity.8 A person may lose interest in life, despair of living, and attempt suicide. Depressed people appear realistic to themselves. Kay Jamison, who has bipolar (manic-depressive) disorder and is also a psychiatrist, does not write much about authenticity in her memoir, and she sees the disorder as a biological illness separate from her identity. By contrast, her sister, who suffered the same condition, saw it as part of herself.9

Kathryn Green-McCreight sees depression as a physical event with spiritual side effects. Depression turns us in on ourselves, and thus can damage the soul, but cannot destroy it.

If my feelings were dead vis-à-vis God, this does not mean that my soul was sick. My brain was certainly sick and my mind was sick, but God held my soul firmly throughout, keeping me longing for him—even though it felt as if I had been abandoned. Abandonment, however, is not God’s way of operating.10

Gender identity is the inner sense of being a boy or girl, man or woman. Usually a person’s inner sense agrees with their biological sex and their physical body. Gender dysphoria is discomfort from having a gender identity that differs from one’s body. Patients may feel trapped in the wrong body, that the body is not part of the self. Often the pain is so great that the person attempts suicide. Depression, anxiety, and co-existing autism diagnosis are common.

“Gender identity disorder” in the diagnostic and statistical manual was renamed “gender dysphoria” to remove the implication that identity was the problem.11 In the West, the predominant treatment for gender dysphoria is gender-affirming therapy, which aims to strengthen a transgender identity by modifying the body. A conservative approach to gender dysphoria, especially before adulthood, is watchful waiting rather than use of hormones and surgery. Often, however, this is considered unethical.

The diagnosis of gender dysphoria has been increasing. Recently, a “rapid onset” type has been described, appearing during puberty or post-puberty, predominantly in biological females. The onset seemed to occur in the context of belonging to a social media peer group where multiple friends became gender dysphoric and transgender-identified during the same timeframe.12

Transgender

Many more people identify as transgender than suffer from gender dysphoria. Transgender people believe that their gender identity is not fully represented by their biological sex. The transgender movement is influenced by queer theory, which teaches that gender identity is fluid and is a choice. By contrast, people with gender dysphoria believe that their gender identity is neither fluid nor chosen. Thus the transgender movement advances contradictory beliefs. If gender is a spectrum, not binary, then everyone is trans, or alternatively, no one is trans.

Almost always, transgender people grow up with unambiguously male or female bodies. While humanity’s sexed nature is fundamentally dimorphic, it is not a simple binary, biologically determined phenomenon. Still, the sexual binary (or polarity) is both useful and truthful, and intersex conditions can be dealt with as exceptions that do not disprove the rule.

A transgender person adopts to various extent the appearance and behavior of the opposite sex, of no gender, or of fluid, changing gender. This can include wearing undergarments of the opposite sex, binding the breasts, wearing artificial breasts or penis, and makeup, external clothing, and hairstyles of the opposite sex. The most extreme changes involve taking puberty blockers (if pre-pubertal), estrogen if a male or testosterone if a female, having one’s body reshaped to resemble the opposite sex (including breast removal or implants, referred to as top surgery), having one’s genitals surgically removed, fashioning artificial genitals from parts of the body such as the colon (referred to as bottom surgery), taking a new name, altering one’s birth certificate, and seeking further public affirmation of these changes.

Perspectives on Justice

Timothy Keller describes five perspectives on justice.13 In the biblical perspective, other people have a claim on my wealth, so I must give voluntarily. Everyone must be treated equally and with dignity. I am sometimes responsible for and involved in other people’s sins. I am finally responsible for all my sins, but not all my outcomes. And, we must have a special concern for the poor and marginalized. The biblical view, Keller maintains, addresses all the concerns for justice found in fragmented form in the other approaches.

The other four perspectives share two assumptions with each other, but not with the biblical view: there are no transcendent moral absolutes, and human nature is a blank slate.

Libertarianism views justice as freedom. From a biblical view it downplays oppressive social forces that make people poor, cannot see any evil in capitalist markets, sees freedom from but not freedom for, and asserts absolute rights over property and self, in conflict with the biblical doctrine of creation.

Liberalism sees justice as fairness for all. Liberal societies have been unable to balance individual freedom with obligation to family and community, leading to loss of social trust and breakdown in institutions.14 Liberalism cannot adjudicate rival rights claims, such as between feminists and transgender advocates. Thirdly, rationality is insufficient basis for a fair society. Finally, liberalism hypocritically excludes religion from the public sphere, while smuggling in beliefs about human nature, rights, sexuality, and other things that are faith assumptions.

Utilitarianism understands justice as the greatest happiness for the greatest number of people. However, Keller thinks that when inevitable clashes occur, majority rules. Many utilitarians consider human rights an obstacle to majority happiness. Biblical objections are that the majority might define harm to suit themselves and oppress the minority, and that real happiness is not found in wealth or pleasures.

Postmodern critical theory posits that all differences in wealth, well-being, and power are due to unjust social structures and systems. Art, religion, philosophy, law, politics, family, and education are determined by social forces. Reality is nothing but power. True knowledge and moral rightness belong to the powerless. People’s moral standing is defined by whether they belong to an oppressed or oppressor group. Reasoned debate and freedom of speech are not valued in postmodern theory. Rather, group membership and not individual actions bring guilt or innocence.

From a biblical perspective, postmodern theory is incoherent. If all thought is socially conditioned, then postmodern thought is also socially conditioned. If power corrupts, than the powerless will also be corrupted when they take power. Postmodern theory denies common humanity and common sinfulness, and makes forgiveness and reconciliation between groups impossible. It builds identity through shaming, othering, and denouncing anyone different. A biblical view recognizes the corrupting effect of power, but gives a model for changing how it is used.

Secularization, Ethics, and the Sexual Revolution

During the high Middle Ages, religion and philosophy—of which natural science was a branch— reinforced each another, such that it was difficult not to believe in God. The Enlightenment initiated a secularization of all areas of life. Some of this was very good. Increased emphasis on the worth and responsibility of every individual is rooted in biblical tradition. But by modern times it becomes increasingly difficult to believe in God.15

Enlightenment thinkers attempted to base morality on universal reason. This effort produced abstract moral principles which were later recognized as products of their own history, while the Enlightenment itself was seen to be historically relative. Postmodernism is a recent movement that adopts a skeptical attitude toward rationality and frames knowledge and values as socially conditioned.

Judaism and Christianity have traditionally afforded respect to expertise and secular wisdom. For example, a Jew is exempted from fasting on Yom Kippur if a doctor states it dangerous to health. Western medicine, however, is increasingly diverging from Judeo-Christian ethics. Religious believers in western cultures must examine the philosophical underpinnings of expert medical opinion.16

Halakha recognizes that the interests of the individual and the group may differ, and both may legitimately be considered. For example, if a Jew is kidnapped, halakha does not limit how much ransom they may pay to obtain their own release. By contrast, there is a limit to what the community may pay, because it must anticipate that paying ransom will encourage further kidnapping.17 (Yet, the state of Israel once released a thousand terrorists in order to ransom a captured Israeli soldier, because of the value it puts on its military ethos.)

Just as there are several modern perspectives on justice, there are several modern ethics. What is reasonable or good in one system may be unreasonable and immoral in another. Increasingly, religiously-based values, practices, and decisions are seen as foolish or evil by arbiters of western culture.

The sexual revolution refers to changes that gained force during the 1960s and continue to this day. The core narrative of this revolution includes heroic individualism, a redemptive trajectory, and a clear moral vision. Radical individualism shifts people’s intuitions away from those that uphold general sacred principles toward those that respond to individual needs. Thus the drag queens in “Pride” parades promote the values of freedom and authenticity (of feelings). The more outlandish, the better. Psychiatrist and Evangelical Glynn Harrison offers this model narrative of the sexual revolution:

For centuries, traditional mortality had us—all of us—in its suffocating grip. Year after year the same rules, chained to the past, heaped shame on ordinary men and women (and boys and girls) whose only crime was being different. Enemies of the human spirit, these bankrupt ideologies befriended bigots and encouraged the spiteful. They nurtured a seedbed of hypocrisy and offered safe havens to perpetrators of abuse.

No more. Change is here. We are breaking free from the shackles of bigotry and removing ourselves from under the dead hand of tradition. Our time has come. A time to be ourselves. A time to be truly who we are. A time to celebrate love wherever we find it. A time for the human spirit to flourish once again. And if you people won’t move out of our way, we are going to push you out of our way.18

David Brooks describes the dominant late twentieth century value of moral freedom this way,

If everybody pursues their own economic self-interest, then the economy will thrive for all. If everybody chooses their own family style, then children will prosper. If each individual chooses his or her own moral code, then people will still feel solidarity with one another and be decent to one another. This was an ideology of maximum freedom and minimum sacrifice.19

A Judeo-Christian critique of the revolution starts with honest self-examination: facing up to shame, hypocrisy, fear, prejudice, and disgust. The sexual revolution ushered in important new freedoms and opportunities, demanded justice and social inclusion. But one can also fault the sexual revolution for failing to deliver on its own promises for human flourishing. The landscape of the revolution includes injustices heaped upon children, more people living alone, the collapse of marriage among the poor, fatherless wastelands of social deprivation, and the “pornographication” (Harrison’s phrase) of childhood.20

Identity involves a narrative we tell about ourselves that gives a sense of meaning and coherence to our lives. Radical individualism combined with major cultural and technological change make it difficult to sustain a stable identity, with risks to mental health and social cohesion. The confusion underpins victimhood identities. Our inner desires conflict and change. Which ones should we follow? Contrary to the self-esteem movement, simply asserting our worth does not convince us. We begin to suspect that our inner hero has been marketed to us.21 The rise in self-harm among young people may be related to fragile modern identities.22

A Better Story

Harrison describes five pillars of the Christian vision for sex and marriage. They are also relevant to Jews and to transgender issues: (1) God has spoken: you don’t have to figure it all out for yourself; (2) God welcomes you into a reality of his making, not yours; (3) We flourish as human beings when we work with, rather than against, the grain of God’s reality; (4) God not only reveals who he is, but he reveals who we are as well; and (5) No matter what happens, God is good. Harrison says Christians need to talk about general moral principles in a way that connects with people’s individualistic concerns for compassion and fairness.

Individualism is not all bad. But there used to be a better balance between individualism and the common good. Reason is neither useless nor all-important, but emotion matters also, and a good story wins hearts. In such a story, our sexual desires connect us with heaven, and the biblical vision of sex confronts shame and opens the road to flourishing as God’s image-bearers. We are called to love in the same way that God loves. The road to flourishing is the way of the cross. God’s love is passionate, always faithful, and ultimately fruitful. As we allow the gospel to shape and discipline sexual desire, our lived bodily experience (single or married) puts these truths on display. Human flourishing is served by God’s gifts of the institutions of the extended family and the local ecclesia.23

Critique of Gender-Affirming Therapy

Gender-affirming therapy is based on the belief that the person’s desire to live as a different gender than their body should be affirmed. There is evidence that people with gender dysphoria have some better outcomes with such treatment,24 and low rates of post-transition regret, but also continuing high rates of suicide, and mental and physical health problems. The treatment can be criticized within its own stated goals, on the gap between theory and practice, and by criticizing the goals themselves.

Many studies have indeed found improved measures of health with gender-affirming therapy, as touted in those studies.25 But they have limitations. The problem with lack of controls is that improvements might also have occurred in similar gender dysphoric people who did not have gender-affirming therapy. The problem with lack of long-term follow-up is that health problems may not be included in study results and evaluation because they do not manifest until several years after hormone treatment or surgery. Other problems introduce potential biases which can threaten study validity. For example, study enrollees whose outcomes are not known (“lost to follow-up”) by the end of the study and therefore not included, often have worse outcomes from those whose outcomes are known and included in the study.

Most but not all conflicts from discordant gender identity could be managed by psychological counseling and support. However, psychological approaches to manage dysphoria have been largely abandoned.26

Laws passed in some jurisdictions to prohibit “reparative therapy” of sexual orientation have in several instances been expanded to prohibit “watchful waiting” approaches to gender dysphoria in children. Mental health professionals may be prevented from offering to help patients to accept their bodies.27 Strong criticism of these restrictions comes from Gender Health Query, whose website describes itself as “a resource & community for LGBT people who want to promote the long-term physical & mental health of gender-dysphoric youth.”28

Trans people have fear around rejection, not being respected, being looked down upon, not having a place in a binary society, and not getting the support they desire for medical transition. This is some of what drives the more extreme behavior among trans activists who lie about, verbally attack and threaten, and try to get people (educators, journalists, mental health professionals, and medical professionals) fired for their viewpoints. There is extremism and cult-like group-think in other activist movements who feel they need to aggressively defend the borders of their community’s identity. This is human nature and deserves compassion and understanding. 

However, the public (school systems, governments, liberal news sites, the mental/medical health community, and LGBT orgs) are allowing activists’ threats and fears of accusations of transphobia to prevent any reasonable discussions around the issue of socially and medically transitioning minors.29

At the Tavistock Gender Identity Development Service (GIDS), the main NHS clinic for gender non-conforming children and young people in the UK, referrals rose from 77 (44% female by birth sex) in 2009–10 to 2,590 (67% female) in 2018-19.30 The clinic says the way children are identifying is changing. Amidst several GIDS staff resignations it was charged that gender dysphoria was over-diagnosed, other mental disorders were overlooked, and medical procedures were given too readily and without true consent. Referrals to gender clinics in the UK plateaued at 2728 in 2019–20. The peak age at referral was 15, when more than 75% were female by birth.31 Concerned observers suggested that what was happening was social contagion in girls, as occurs in self-harm and eating disorders.32

About 80% of children referred to Tavistock before adolescence change their gender identity to align with their biological sex, many adopting a gay or bisexual identity, while about 80% referred as adolescents ultimately pursue sex reassignment.33 Attempted suicide rates are 27% for those identifying as trans, compared with 11% for all young people. Completed suicide rates are 19 times as high in people who undergo transition surgery, compared to nontrans controls matched on birth year and birth sex.34 Over their lifetime, over 40% of transgender persons report they have attempted suicide.35 Thus, rates of suicide attempts and completed suicides are higher in transgender people both before and after transition, compared to the general population. Transgender supporters emphasize external factors in suicides,36 but factors both internal and external to the individual contribute.37

An editorial in the British Journal of General Practice voiced many concerns about low quality studies or lack of studies of gender-affirming therapy. Psychiatric assessment is often rejected. Gender dysphoria may be affected by social and cultural context and has the potential to change over time. While helping some, interventions can result in ongoing side effects and medical dependency. NHS material contains concepts that biological sex is assigned at birth (rather than observed) and that surgery can change sex. The wide range of treatment experiences and outcomes including desistance need to be included.38

Professor Carl Heneghan, director of the Oxford University Centre for Evidence Based Medicine, concluded that gender-affirming therapies are “an unregulated live experiment on children.”39 Problems with studies of puberty blockers and cross-sex hormones included lack of controls or inadequate controls, lack of blinding, small sample sizes, loss to follow-up, not reporting adherence to treatment, and subjective outcomes.

An Archive of Diseases in Childhood letter referred to GnRHa (gonadotropin-releasing hormone analogue, a puberty blocker) treatment as a “momentous step in the dark.” It set out three main concerns: 1) young people are left in a state of “developmental limbo” without secondary sexual characteristics that might consolidate gender identity; 2) use is likely to threaten the maturation of the adolescent mind; and 3) puberty blockers are being used in the context of profound scientific ignorance.40 Heneghan concluded, “The current evidence base does not support informed decision making and safe practice in children.”41

A recent correction to a research article that supported Sex Reassignment Surgery (SRS) retracted its main point. Upon reanalysis of the data, individuals diagnosed with gender incongruence who had received gender-affirming surgical treatments demonstrated no advantage of surgery in relation to subsequent mood or anxiety disorder-related health care visits or prescriptions or hospitalizations following suicide attempts.42

Religious Reponses to Transgender Issues

Groups and material selected below are not all-inclusive. I stopped adding material when all important positions were represented.

Roman Catholic

Helen Watt explored the implications of the Holy See’s direction that “Everyone, man and woman, should acknowledge and accept his sexual identity.” Which responses to gender dysphoria might this preclude?

Watt argues that there must be some limits on permanently disabling procedures to relieve distress, even for the health of the whole organism. A person distressed by their ability to speak might need different treatment than one distressed by their ability to smell, because rational communication is so important. An obsessive-compulsive person might be distressed by making moral choices, but making moral choices is crucial to the moral life. Watt finds it abhorrent, even for the sake of overall health, to permanently obstruct the parts of the brain responsible for empathy, remorse, or spirituality. Removing one’s reproductive organs may be more problematic than removing a limb, even for psychological well-being, because of the “transcendent” aspect of reproduction, linking to later generations and to the divine.

Biological sex is important to the goods of marriage and family, Watt continues. But modifying one’s body, clothing, and behavior to appear as the opposite sex will inevitably persuade many that they are the opposite sex. And people who are affirmed in their wish to be the opposite sex (e.g. by gender-affirming therapy) may become convinced they are the opposite sex. Thus, deceiving others about one’s sex, though possibly justifiable for psychological reasons, has wide and deleterious consequences. What about self-deception? An adult with anxiety may find it comforting to sleep with the blanket they used as a child, all the while knowing they are no longer a child. This “self-deception” is not immoral and may help the adult fall asleep. Other deceptions are more concerning, such as a woman who gives up her baby for adoption, and then denies she is a biological mother. Altering the body and erasing history in association with gender transition almost unavoidably imply different family relationships than one’s biological sex would indicate. The transgender person wants to be son rather than daughter, father rather than mother, and so on. The child of a transitioning parent will be left with no mother or no father unless the adult recognizes the continuing role relationship.

If, writes Watt, the mere existence of some deep-seated feeling gives a person reason not only to acknowledge, but also to accept and celebrate that feeling, psychological and moral self-improvement loses any anchor it might have. “Do what you feel” is often not very helpful guidance: admit what you feel is a better general guide to mental health and moral well-being. Feelings of rejection of one’s biology therefore demand not “acceptance” in any positive sense but at most “acknowledgement,” as part of an honest assessment of one’s inner life. Instead, biological sex, like family membership, seems a suitable candidate for our basic identity in the sense of what anchors us objectively in the world.43

Orthodox Judaism

After defining “transgender” and “gender dysphoria,” Rabbi Gil Student’s blog entry “Transgender and Judaism” states that for [Orthodox] Judaism, biology determines gender.44 The biblical prohibition of cross-dressing was further interpreted to prohibit men from acting like women and vice versa. Different reasons were given for the prohibitions. Maimonides wrote that cross-dressing occurred during idolatrous practices, and also leads to sexual impropriety, including auto-eroticism. Rashi thought that cross-dressing might be used for deception. Student considered all three reasons relevant today. Ibn Ezra agreed with Rashi about transvestism, but further commented that God despises someone who changes a divine act. Student suggests this refers to unnatural methods in marital relations, or could be a general statement about Judaism and gender. Abarbanel offered two reasons for prohibiting cross-dressing: prevention of licentiousness or impropriety, and because you may not change the biological gender God gave you. Samson Raphael Hirsch and Rav Asher Meir followed this second explanation. Student concludes:

The concept of biological gender as a binding legal construct must be acknowledged. Feeling uncomfortable with one’s gender is unobjectionable. Acting or dressing contrary to one’s biological gender is considered disturbing God’s plan with the world.45

Rabbi Dr. Tzvi Hersch Weinreb also addressed transgender issues.46 Weinreb’s professed goal was to foster love for one’s fellow Jew and fellow man, and to speak dispassionately about science and halakha.

The Talmud discusses androgynous people, people with both male and female physical features. The indeterminate person was considered male (the stricter view) for purposes of being obligated to time-bound commandments. Intersex condition is different from transgender people, who are anatomically completely one sex.

There is virtual unanimity among Orthodox rabbinic authorities that hormonal and surgical interventions to change gender are prohibited, for four biblical reasons:
(1) castration is forbidden to all people; (2) it is forbidden for a Jew to dress as the opposite sex; (3) wounding oneself is forbidden, because your body belongs to God, not to you; (4) unnecessarily endangering your health (in these medical procedures) is forbidden.

Weinreb noted exceptions to all these prohibitions. The major exception is pikuach nefesh—for saving a life. Does gender dysphoria require a response of pikuach nefesh? In some situations, he agreed that it does. This will be determined with the help of psychiatric consultations.

Suppose a person undergoes SRS and becomes transsexual. What is their obligation? The majority of [Orthodox] rabbis rule that one’s gender at birth is one’s gender throughout life. Rabbi Weinreb follows Rabbi Idan ben Ephraim, who thinks activities which are performed in private should be consonant with one’s birth gender. However, for public activities, such as whether one sits in the men’s or the women’s section at shul, the transsexual person should sit with those whose appearance they have taken on. Moreover, reversing SRS is discouraged as too dangerous. The underlying ethos is that all Jews are welcome in the synagogue and Jewish community and should be encouraged to perform mitzvot to the extent they are able.

Gender non-conforming children are subjected to high rates of bullying. In the UK, the Chief Rabbi and LGBT+ people contributed to guidelines to prevent bullying in Orthodox Jewish day schools.47

Evangelical and Conservative Christian

Mark Yarhouse outlines three lenses for viewing transgender issues.48

The integrity lens, based on a straightforward reading of Scripture, sees “male and female” as the order of creation. Jesus affirmed Genesis 1–2 in Matthew 19, and in the same chapter recognized eunuchs as special cases. Thus, gender and biological sex should be aligned. But transgenderism violates God’s original design.

The disability lens, a post-fall “Genesis 3” approach, likens transgenderism to other mental illnesses such as anorexia and depression. It is not a moral choice. But how one responds to it is a moral choice. With therapy, gender dysphoria can be managed and relieved to some extent.

The third lens, diversity, affirms and celebrates transgender identity. It meets the need to feel included. Yarhouse draws in part on all three lenses, and has been followed by others.

Andrew Sloan notes that humans are fundamentally relational. Sex and gender inform our identity and God-given task in the world (Gen 1:26–31), but do not define us. In the body-obsessed modern world, medicine is a commodity purchased to bring the resistant body under control of the will, which renders even our embodied selves into commodities. This view of medicine, says Sloan, must be replaced by one in which medicine expresses a community’s solidarity with and care for the frail. In such a view, medicine has a clear but limited role in the care of people with gender dysphoria. Radical surgical intervention may be warranted as a treatment of last resort, but it will not fix problems rooted in culture. Much distress will be alleviated by allowing a wider range of expressions of masculinity and femininity within Christian communities.49

Sam Allberry, a pastor with same-sex attraction who is celibate, interprets Romans 1 as revealing that all of us are broken, all of us are futile in our thinking. The hope for our brokenness is that Jesus went through the ultimate brokenness.50

Conservative Judaism

The Rabbinical Assembly of Conservative Judaism issued responses on transgender issues in 2003 and 2017. While both affirmed transgender identity, the second critiqued the first. The earlier document viewed gender as binary male or female, while the later saw gender on a spectrum which included no gender.

Rabbi Meyer Rabinowitz reviewed the Talmudic prohibitions of castration, cross-dressing, endangering oneself (here through surgery), and changing what God has created, and ancient rabbinic through contemporary Reform and Orthodox Jewish decisions. Among the contemporary Orthodox, Waldenberg determined gender for halakhic purposes by the external genitalia, while Tendler and Rosner based normative gender on sex chromosomes. Rabinowitz understood Waldenberg as believing that sex could change. Agreeing that sex could change, Rabinowitz permitted SRS lachatkhila (from the beginning, not merely justifying an action after the fact) when based on medical opinion that it is for the good of the patient, to relieve gender dysphoria.51

Rabbi Dr. Leonard Sharzer surveyed Jewish tradition as he sought to rule how gender identity should be treated halakhically. Contra Rabinowitz, Sharzer thought Waldenberg had stated that actual genital organs, not surgical approximations of them in SRS, determined sex and gender. Rabbi Sharzer also claimed that Waldenberg was acting under the discredited theories of John Money that gender identity was malleable until 18 months of age, and infants could have their sex surgically assigned at birth and hormonally regulated without negative consequences.

Sharzer claimed rabbinic precedent for applying halakhic paradigms in a non-rigidly binary fashion. He advised accepting the gender identity of the person with gender dysphoria, as most respecting of their dignity and least likely to produce psychological distress. Sharzer took up a number of ritual questions regarding transsexuals, such as conversion, marriage, and burial. He advocated approaching people as individuals, recognizing that there will be inconsistencies and contradictions.52

A colleague of Sharzer on the Committee on Jewish Law and Standards (CJLS) of the Rabbinical Assembly questioned whether cisgender heterosexuality should be seen as normative, with other expressions as non-normative, but excused. He wondered, “Are we promoting tolerance or true acceptance?”53 This implies that the disability lens is not true acceptance of transgender people.

Reconstructionist Judaism

Rabbi David Teutsch believed that because everyone is created in the image of God, their diversity adds to the presence of God among us. He held that the Talmudic rabbis considered gender and sex independent variables and made it licit for transgender people to be true to themselves in gender expression. By limiting the prohibition of cross-dressing to situations of deception, the tradition permitted cross-dressing when it is true to the cross-dresser’s identity. Teutsch considered hormone therapy exceptionally safe and SRS similar to plastic surgery.54

Clearly, Teutsch operated with a diversity lens and notably decided not to validate a disability lens. For him, deception is not giving the appearance of being a different sex; it is giving an appearance different from one’s inner feelings of identity.

Jew and Christians with Gender Dysphoria

The organization Keshet describes itself as “for LGBTQ equality in Jewish life.” In one of the stories on its website, a trans man narrates episodes from a visit to a synagogue: social hall, restroom, sanctuary. They reflect on deception, authenticity, and the “transgendering” of the Torah Scroll.55

The website of Austen Hartke (http://austenhartke.com/trans-faith-resources) features several stories by Christians who transitioned from one gender to another. Lawrence Richardson spoke at Chicago Theological Seminary of being rejected by their church and of struggling and reaching self-acceptance.56

Hartke spoke at the Reformation Project. Biblical passages that comfort or challenge transsexuals were discussed. Among the former is Isaiah 56:3–5, about eunuchs. Among the latter are the creation story and prohibitions of cross-dressing (Deut 22:5) and castration (Deut 23:1). Hartke pushed aside the gender binary with examples of animals such as the platypus that fall outside categories. The prohibition of cross-dressing was countered by examples of males wearing kilts in other cultures. Here I must object. The mistake in this analysis is that every culture has clothing to distinguish men from women. Wearing a kilt in context is not an attempt to impersonate a woman, in contrast to people with gender dysphoria who dress to pass as the opposite sex. The prohibition against castration Hartke claimed not relevant because castration was used as capital punishment. This argument seems irrelevant, as the verse states such a person may not enter the congregation of the Lord, which is only meaningful if they are alive. Encouraged by the wounds Christ bore after his resurrection, Hartke envisioned their raised spiritual body displaying the scars of top surgery.57

The Evangelical Alliance website carried an interview with Jeanette Howard. As a child she thought of herself as a third sex, and years later supposed that had she had been born in 1998 instead of 1958, she would have been steered toward puberty blockers. If she had been asked as a child, Jeanette would have welcomed cross-sex hormones and surgical transition to a male.58 Instead, in those times, she did not speak up about her dysphoria, but enjoyed stereotypically male activities. When puberty came, she wanted women as friends or lovers, hated the development of her breasts, and welcomed the androgynous fashions of the times. There followed three long-term lesbian relationships. In the midst of the last, she became a Christian and read in Scripture that her identity is in Christ. Her conversion was delayed about six months because she knew the cost.

About two years after her conversion, a mentor advised her to look in the mirror every morning and say, “Thank you God, for making me female.” Jeanette thought it bizarre, but did it. The next morning, standing before the mirror, she was unable to look up, much less say the words, because what she saw was not how she felt. Yet she persisted. She knew she had to come into agreement with Psalm 139, which says, “I am fearfully and wonderfully made.” By pursuing truth, she found intimacy with Christ.

Drawing the Strands Together

Scripture and right reason testify that humans are normatively two sexes: male and female. Gender identity and gender expression normatively follow biological sex, and a self includes both mind and body. In life there are many exceptions to God’s good creative intent.

Gender dysphoria shares some similarities with body identity integrity disorder, anorexia nervosa, and some forms of depression. It is appropriate to treat all as mental or brain diseases.

Transgender people form their gender identities around their minds, which they find their bodies do not match well. They seek to change their bodies to align with their minds. Some but not all have gender dysphoria. Some consider gender fluid; others, that it is fixed. A large number of people in the west today, including many mental health professionals, disagree that transgender identity manifests a mental or brain disease.

Changes in culture help to explain how transgender issues came to the fore now. Emphasis upon freedom, individualism, and authenticity meant that the expression of inner desires and feelings was not weighed against external or divine standards but instead considered self-validating and essential to flourishing. But our inner feelings, especially in conflict with our bodies, do not, or do not always, sustain a stable identity. The harmful consequences of fragile identities is evident in self-destructive behaviors, mental disabilities such as depression, and inability to tolerate having one’s ideas challenged.

Evidence for the long-term effectiveness of gender-affirming therapy is limited and mixed. Most people who transition to live as a different gender than their birth sex report a lessening of dysphoria and do not regret SRS. However, they continue to have high rates of both physical and mental co-morbidities and of suicide. Furthermore, there is strong evidence for social contagion of adopting transgender identity.

Within the medical community, the use of puberty blockers is controversial. One side argues that by diminishing gender dysphoria, puberty blockers clear young people’s minds so that as adolescents they can better decide whether to transition to live as the opposite sex by initiating cross-sex hormones and surgery. The other side argues that puberty blockers leave young people without the secondary sex characteristics that help them consolidate a gender identity and inhibit maturation of the adolescent mind. The resolution of these medical controversies lies in part with further medical research that addresses the weaknesses of past studies, and in part with a critique of western culture.

Voices within the religious communities surveyed here—Roman Catholic, Orthodox Jewish, Evangelical and Conservative Christian, Conservative Judaism and Reconstructionist Judaism—agree that gender dysphoria is a serious affliction that persons in the faith community must try to alleviate. Such a view is consistent with both individualism and more communal sensibilities, including biblical ones.

The treatment of transgender issues within Conservative Judaism’s Rabbinic Assembly is questionable. Two authors accept medical opinion about gender-affirming therapy as uniformly favorable, when it is not. They do not distinguish between individual and communal interests, or between a disability and a diversity lens, instead jumping from medical opinion to constructing public rituals that affirm transgender identity. They thereby damage the integrity lens (the integrity both of Scripture and the physical world) and further social contagion. A third rabbi on the CJLS probably damages the disability lens with remarks about acceptance versus toleration. The author with the Reconstructionist movement also has an overly rosy view of gender- affirming therapy and rejects the disability lens.

I think that we need to offer people with gender dysphoria more than toleration. Rabbi Jonathan Sacks spoke on “Rethinking Failure.”59 Perhaps, he suggested, our failures are actually our strengths. Moses had a speech impediment. Maybe because he couldn’t speak, he learned to listen. Rabbi Akiva started studying Torah at age 40. It is much harder to learn in maturity than at a young age. Perhaps because Akiva knew how hard learning is, he became the best teacher. Reish Lakish had a career as a highwayman, a man of violence, before he turned around. He had great perception about the power of repentance. The father of Adin Steinsaltz was secular and an atheist, but he sent his son to Yeshiva, saying, “I want my son to be a heretic, but not an ignoramus.” Rabbi Steinsaltz became able to explain the Talmud to secular people.

The other three religious communities discussed above would probably agree on several positions. With the Roman Catholics, all could and would probably agree that “Everyone, man and woman, should acknowledge and accept his sexual identity,” the intrinsic unity of a person as body and soul, the goods of marriage and family, the moral hazards of certain forms of deception, and that admitting your feelings is a better guide to mental health than “do what you feel.” Propositions advanced within Orthodox Judaism and by Evangelical and Conservative Christians could similarly be acceptable to the others.

The testimonies of Christians or Jews with gender dysphoria are important to listen to, not least because they ask for our friendship and accompaniment in their suffering, just as they can offer friendship and accompaniment to others who are broken in various ways. Not all people with gender dysphoria choose to pursue a transgender identity.

Conclusion

I approach transgender issues through medical studies, philosophy, theology, history, and stories both personal and imagined. I hope to provide a foundation for caring relationships, although that is not the focus of my inquiry. I hope that by pursuing certain questions of fact, it will be easier to bear uncertainty and gaps in our knowledge. Yet some things can be said already.

Points to Affirm

1. The body gives each person their sex and gender.

2. In humans the sexual and gender polarity of male and female is normative.

3. Three lenses of integrity, disability, and diversity are useful for responding to transgender issues.

4. A disability may become a strength.

5. We need to both support transgender people, who we want to include in our congregations, and promote valuable gender norms. Perhaps we can promote a wider range of masculinity and femininity.

6. Before psychological and medical consultation over gender dysphoria, persons of faith need to know if their therapists respect their faith perspective. They should seek professionals who are willing to present all treatment options, their risks, the limitations of what treatment can accomplish, and possible benefits, and will work toward the goals set by the patient.

7. People of faith can make common cause with transgender advocates in opposing bullying and other forms of discrimination.

The issues raised by transgender identity are fundamental, which is why the biblical creation story is so relevant to them. Whether I consider myself a mind trapped in the wrong body, versus a child of God created male or female in God’s image, loved and called by God, is not just a thought, but a framework for all other thought and for living. Some people will be assisted to affirm the goodness of the body by reason, experience, Scripture, tradition, or all these ways and more. Yet in our broken condition, some people will never feel comfortable in their skin. God calls us to love our neighbor, even these neighbors.

Much of Dr. Jon Olson’s (DPM, DrPH) current work in epidemiology is related to the COVID-19 pandemic. He tries to balance in-person and virtual meetings, and to walk outside among trees every day.