LCMS Convention Workbook St. Louis, Missouri — 2016, Page 172

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172

IV. THEOLOGICAL DOCUMENTS­­—COMMISSION ON THEOLOGY AND CHURCH RELATIONS

Gender Identity Disorder or Gender Dysphoria
in Christian Perspective1
“Gender” has become a matter of uncertainty. Rather than male or female, many see gender as a
relative matter, or even a continuum. They consider gender or sexual identity to be less a reality
given at conception than a matter of personal discovery.2 Reflective of such a theoretical
perspective, increasing attention is also given to individuals who are personally uncertain about
their own gender or sexual identity—in particular, individuals who are “transsexual” or
“transgendered,” 3 as well as those who identify themselves as “bisexual” or are “questioning”
their gender and in the process of determining what they perceive to be their true gender
identity.4
In recent years the Commission on Theology and Church Relations has been asked about the
specific matter of transsexual or transgendered individuals. Questions have come from
individuals with personal questions about sexual identity including persons who are uncertain
whether they are “truly” male or female, others who are regularly dressing and presenting
themselves as a member of the opposite sex, and still others who are participating in hormonal or
surgical procedures to change their sex identification from male to female or from female to
male. In addition to concerns from individuals questioning their sexual identity, church workers
have asked for guidance in pastoral care for individuals struggling with matters of gender
identity.
The following pages will consider, first, some of the current psychotherapeutic perspectives of
the American Psychiatric Association. Those perspectives are important, yet Christian churches
seek a theological understanding as grounded in the higher authority of God’s revelation in
Scripture. Thus the remainder of the report provides theological reflection on the topic of sexual
identity and suggestions for pastoral care.

Psychotherapeutic Considerations
The American Psychiatric Association’s (APA) 1994 Diagnostic and Statistical Manual of
Mental Disorders, 4th Edition (DSM-IV) listed four criteria required for a person to be diagnosed
with gender identity disorder (i.e., as a transsexual or transgendered individual):
 Strong and persistent cross-gender identification;
 Persistent discomfort about one's assigned sex or a sense of inappropriateness in the
gender-role of that sex;
 The individual does not have a concurrent physical intersex condition
[hermaphroditism5];
 Clinically significant distress or impairment in social, occupational, or other important
areas of functioning.6
In recent years, these criteria and the APA’s 1994 categorization of the condition as a “disorder”
have stirred controversy within the psychotherapeutic community together with impassioned
debate. The primary concern that many have had with DSM-IV has been the assumption that
identifying with a gender other than the one assigned at birth is a “disorder.” The label
“disorder” is thought to imply a value judgment. For example, the doctor who chaired the gender
identity disorder committee of the APA has been criticized by many because he advocates
cognitive behavioral treatment for the disorder in children (although he does not advocate such
treatment for adults).7
As a result of the debate the most recent edition of the Diagnostic and Statistical Manual of
Mental Disorders, 5th Edition (DSM-58), released in May of 2013, discontinued the term “gender
identity disorder” in favor of “gender dysphoria.” 9 DSM-5 distinguishes between gender
dysphoria in children and adults. It defines “transgender” persons as those “who transiently or
persistently identify with a gender different from their natal gender” and “transsexual” persons as
those who either seek or have undergone “a social transition from male to female or female to
male” whether or not that entails hormonal or surgical treatments.10 DSM-5 continues to
maintain a distinction between sexual dysphoria and an intersex condition (in which an
individual has physically or genetically ambiguous sexual traits). “Overall, current evidence is
5

As Lutheran Christians, a consideration of The Lutheran Church—Missouri Synod on this and any topic is
grounded in belief in the full authority of Holy Scripture as God’s infallible Word and the conviction that the
Confessions of the Lutheran Church are a truthful interpretation of the Scriptures. The general perspective of this
report, however, is one that is not simply that of the Lutheran theological tradition, but rather stands within the broad
(catholic) consensus of traditional Christian teaching.
2
This is an element of what is sometimes referred to in gender studies as the “social constructionism” movement in
psychological theory. As an example, see Rachel Alsop, et al., Theorizing Gender: An Introduction (Malden,
Massachusetts: Blackwell Publishers, 2002).
3
For the purposes of this document, the definitions of transsexual and transgender used by the American Psychiatric
Association are utilized. See the text below under Psychotherapeutic Considerations for those definitions (p. 2).
4
Note the familiar acronym LGBT (Lesbian, Gay, Bisexual, Transgendered) to which is now frequently added Q for
Questioning—LGBTQ. Both acronyms are regularly present not only in secular discussions, but also in ecclesial
settings. Ecclesial LGBT(Q) lobbies have pressed church bodies to make changes allowing ordination into the
ministry and religious blessing of same-sex unions or marriages of practicing homosexual persons. Such lobbies are
also advocates for Bisexual and Transgendered individuals and others who are Questioning their sexual identity.

A hermaphrodite is a person having both male and female sexual tissues. It is an older term for a condition now
included under the term “intersex” which is defined in the body of this section or described by the phrase “disorder
of sex development” (DSD).
DSM-IV (Washington, DC: American Psychiatric Association, 1994) 537-538.
7
Dr. Kenneth Zucker is a sexologist who specializes in the care of children with gender dysphoria. He favors
cognitive behavioral therapy only in children and disavows reparative therapy for homosexuals. “Kenneth Zucker.”
Wikipedia, The Free Encyclopedia. <http://en.wikipedia.org/wiki/Kenneth_Zucker> (accessed: 29 October 2013).
Cognitive behavioral therapy in this context may be generally defined as a therapeutic process that attempts to help
an individuals change their sexual identity. In this case, Zucker’s approach seeks to help children who are
identifying with the opposite sex to be accepting of their own sex as a boy or girl.
8
DSM-IV and predecessor editions were identified by Roman numerals when abbreviated. DSM-5 uses the Arabic
numeral.
9
DSM-5 (Arlington, Virginia: American Psychiatric Association, 2013), 451-459. Dysphoria is medically defined as
“an emotional state marked by anxiety, depression, and restlessness” (dysphoria. Dictionary.com. The American
Heritage® Stedman's Medical Dictionary. Houghton Mifflin Company.
http://dictionary.reference.com/browse/dysphoria [accessed: 29 October 2013]).
10
DSM-5, 451.

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insufficient to label gender dysphoria without a disorder of sex development as a form of
intersexuality limited to the central nervous system.”11
Gender dysphoria in both children and adults is reportedly more prevalent in males than in
females. For adults identified as male at birth, the incidence reported in DSM-5 is between
0.005% to 0.014% (5-14 cases in every 100,000 males). For adults identified as female at birth,
the rate is from 0.002-0.003% (2-3 cases in every 100,000 females). No global prevalence data is
offered for gender dysphoria in children, but the ratio from many international studies again
suggests a greater rate of occurrence in boys compared to girls (between 2 and 4.5 times as often
for boys as for girls). In a final note on prevalence, however, DSM-5 indicates that Japan and
Poland report more sexual dysphoria in females than in males.12 (No further information on any
of the data is given and DSM-5 does not indicate either the sources of the research or its sample
populations.)
In an online pamphlet released in advance of DSM-5, gender dysphoria is described as follows:
For a person to be diagnosed with gender dysphoria, there must be a marked
difference between the individual’s expressed/experienced gender and the gender others
would assign him or her, and it must continue for at least six months. In children, the
desire to be of the other gender must be present and verbalized. This condition causes
clinically significant distress or impairment in social, occupational, or other important
areas of functioning.
Gender dysphoria is manifested in a variety of ways, including strong desires to
be treated as the other gender or to be rid of one’s sex characteristics, or a strong
conviction that one has feelings and reactions typical of the other gender.13
DSM-5 itself states: “Gender dysphoria refers to the distress that may accompany the
incongruence between one’s experienced or expressed gender and one’s assigned gender.” It
furthermore indicates that “[t]he current term is more descriptive than the previous DSM-IV term
gender identity disorder and focuses on dysphoria as the clinical problem, not identity per se.”14
In taking this stance, the APA is acknowledging both the afore-mentioned debate and also the
complexity of the research that has been conducted in this area. While an intersex condition (see
below) is rather distinctive and clearly involves biological and genetic criteria, the causes of
individual distress over one’s apparent sex—one’s “natal gender”15—are highly complex. There
is no certain physiological or genetic cause for such dysphoria.

11
DSM-5, 457. In other words, there is insufficient evidence to suggest that gender dysphoria has a biological cause
unless it is accompanied by sexual ambiguity of a physical nature (intersex condition or DSD). DSM-5 cites
evidence that hormonal levels for natal males with sexual dysphoria are similar to those for the male population
without sexual dysphoria. Hormonal levels for natal females with sexual dysphoria indicate a slightly higher, but
statistically insignificant, level of testosterone than found in the average female population.
12
DSM-5, 454.
13
See http://www.dsm5.org/Documents/Gender%20Dysphoria%20Fact%20Sheet.pdf (accessed 29 Oct. 2013).
14
DSM-5, 451; emphases in the original.
15
The term “natal gender” is used and defined in DSM-5, 451 as the identity associated with biological indicators
that is given to an individual at birth.

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The change in terminology from DSM-IV to DSM-5 is significant because it indicates a
reluctance to identify the confusion that an individual may feel about whether he or she is male
or female, despite his or her natal gender, as a clinical problem. Rather than an identity disorder,
DSM-5 only recognizes the distress the individual feels as a treatable problem. This suggests that
the debate with its consequent conceptual and terminological changes has occurred in large
measure because a value judgment is perceived to be at the heart of the notion that cross-gender
identification is itself a “disorder” and therefore detrimental or negative.
Viewing sexual identity from a perspective of ordered or disordered implies a moral judgment,
with “good” versus “bad” implied. Such moral reflection has been progressively excluded from
the fields of psychology and psychiatry in recent decades. The elimination of homosexuality
from the list of psychiatric disorders on December 15, 1973 is a relevant example. That
elimination was grounded primarily in the conviction that it was a moral value judgment to
declare homosexuality a psychiatric disorder that should be treated.
The continuing debate regarding homosexual conduct in the United States is in large measure a
debate between a biblical and traditionally Christian understanding of the moral quality of
homosexual behavior and the understanding, adopted by an increasing percentage of those in the
psychiatric community since 1973, that homosexuality is either a natural condition or a valid
lifestyle alternative. The underlying question is whether there is space for moral judgment in
determining human behavior that requires psychiatric or psychological therapeutic care. The
trajectory of past thinking and current DSM judgments indicates a similar perspective about
matters of gender identity, namely, that such dysphoria should not be viewed in any way that
involves moral judgment. The APA therefore approaches such an issue from a significantly
different standpoint than the standpoint of Christian theology.

Christian Moral Reflection on Gender Identity
Christian theological and moral reflection on matters of gender identity must note the trajectory
indicated above and its basis in the 1973 decision of the APA. An underlying assumption of
those who press for changes in the church’s understanding of homosexual behavior has been that
one’s embodiment should not be a determinative factor in moral behavior. In other words, simply
because one is physically male, he should not have to accept that the natural and God-pleasing
sexual expression appropriate to him should be toward females. And, if one is physically female,
she should not feel morally compelled to restrict any sexual desires for women. Similarly, one
who has sexual desire for both men and women, should not seek to deny such desires or feel
compelled to restrict his or her sexual contact only to the opposite sex. And, lastly, just because
one has male genitalia, one should not be encouraged to seek treatment for the fact that one feels
more like a female.
The entire Christian tradition and the majority of Christian churches today have opposed such
changes in perspective. The basis for such opposition is precisely because our embodiment is
understood as an aspect of our creation by God and therefore instructive regarding behavior that
is good and pleasing to Him. Human embodiment indicates simply and eloquently God’s
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