The mission of Issues in Perspective is to provide thoughtful, historical and biblically-centered perspectives on current ethical and cultural issues.

More recent cultural shifts around gender identification and the push for transgender rights represent a profound change in society that has led to battles over medical procedures for minors and public school policy.  For example, former President Biden proclaimed that Easter Sunday 2024 was also the 2024 Transgender Day of Visibility. He declared to the transgender community: “You are America, and my entire Administration and I have your back.”  That this “Day” also occurred on Easter Sunday provoked outrage and anger—understandably.  Arguably quite political in nature, Biden’s proclamation backfired and further eroded the legitimacy of the transgender revolution.

In this Perspective, I hope to place this cultural phenomenon in a helpful context.  First of all, medical claims are quite relevant to the transgender movement.  But the medical claims seeking to legitimize transgenderism are coming under severe scrutiny.  For example, in April 2024, Hilary Cass, a British pediatrician, published her review of gender-identity services for children and young people, commissioned by NHS England.  It cast significant doubt on the evidence for youth gender medicine.  As The Economist reported, “This prompted the World Professional Association for Transgender Health (WPATH), the leading professional organization for the doctors and practitioners who provide services to trans people, to release a blistering rejoinder. WPATH said that its own guidelines were sturdier, in part because they were ‘based on far more systematic reviews.’”

But court documents recently released as part of the discovery process in a youth gender case in Alabama reveal that WPATH’s claim was built on shaky foundations.  “The documents show that the organization’s leaders interfered with the production of systematic reviews that it had commissioned from the Johns Hopkins University Evidence-Based Practice Center (EPC) in 2018.”  The Economist article documents the attempt of WPATH to “exert undue influence over what was supposed to be an independent process.”  Complex negotiations ensued between EPC and WPATH with WPATH “implementing a new policy in which WPATH would have authority to influence the EPC team’s output—including the power to nip papers in the bud on the basis of their conclusions.”  The Economist therefore concluded that “Questions remain unanswered, but none of this helps WPATHs claim to be an organization that bases its recommendations on science.”

Second, a few comments on the important Supreme Court case, United States v. Skrmetti, that challenges Tennessee’s ban on “medical procedures” that permit “a minor to identify with, or live as, a purported identity inconsistent with the minor’s sex.” This ban includes the use of puberty blockers and cross-sex hormones. It does not apply to adults.

Christian attorney and columnist David French provides some important background to this case:

• “American law recognizes several important differences between children and adults, and one of the chief differences is that minors are deemed incapable of granting informed consent to medical procedures. They’re too young to understand the risks and rewards, and too susceptible to adult influence to be independent thinkers.  Typically, this means that parents step in as proxies. Parents are the ones who consent to medical treatments for their children, and they’re the ones who sometimes make life-or-death decisions regarding the welfare of their children. But parental authority is not absolute, including when it comes to deciding which treatments are available.  Parents can’t dictate the approval or availability of any given drug. They can’t require hospitals to provide specific surgical services. And states still exercise oversight of child welfare. In Tennessee, for example, a child can’t get a tattoo even with parental permission (except to cover up an existing tattoo).”
• The decision to approve any given drug for public use is typically made by the political branches of the government. At the federal level, the Food and Drug Administration — an executive agency authorized by Congress — governs the process, and, as the Court of Appeals for the Sixth Circuit explained in its own ruling in this case, “the Constitution rarely has a say over the F.D.A.’s work.”  “As long as the government’s choice is deemed ‘rational,’ it’s permitted, and then the recourse is to politics, not the courts, to change the government’s decision. To pass the test, the state has to show only that the law advances a legitimate state interest and that there is a rational connection between the law’s means and its goals.”

As mentioned above in reference to the WPATH and EPC dispute, perhaps the single most consequential and rigorous examination of the safety and efficacy of gender-affirming medical interventions is the Cass Review, a comprehensive survey by Dr. Hilary Cass of research on gender-affirming medical treatments for minors. Britain’s National Health Service commissioned the review to make recommendations on how to improve N.H.S. gender identity services and to make sure that children experiencing gender dysphoria experience a “high standard of care.”

• Cass described the field of study as “an area of remarkably weak evidence.” Even worse, “the results of studies are exaggerated or misrepresented by people on all sides of the debate to support their viewpoint.” Her conclusion was sobering: “The reality is that we have no good evidence on the long-term outcomes of interventions to manage gender-related distress.”
• The report also highlighted the way in which the medical community typically takes a cautious approach to new medical interventions. But, as Cass argues, “Quite the reverse happened in the field of gender care for children. Based on a single Dutch study, which suggested that puberty blockers may improve psychological well-being for a narrowly defined group of children with gender incongruence, the practice spread at pace to other countries.”

French also adds some important details to the Tennessee’s case before the Supreme Court. There can be serious side effects to medical treatments. As the State of Tennessee contended in its brief to the court, “giving girls high doses of testosterone induces severe hyperandrogenism that can cause clitoromegaly, atrophy of the lining of the uterus and vagina, irreversible vocal cord changes, blood-cell disorders and increased risk of heart attack.”  In addition, “giving boys high doses of estrogen induces hyperestrogenemia, leading to a ‘very high risk of’ blood clots and increased risk of tumors, breast cancer, coronary artery disease, cerebrovascular disease, sexual dysfunction and gallstones.”

French forcefully concludes that “It is deeply unfortunate that the public debate over gender-affirming care for kids has been tainted by extreme intolerance. Researchers are often frightened to present results at odds with the desires and goals of at least some activists for transgender rights. A scientific consensus achieved through threats and intimidation is no consensus at all . . . Their theory is that the Tennessee regulation isn’t a conventional medical regulation but rather a form of sex discrimination. As the solicitor general, Elizabeth Prelogar, argued on Wednesday, the Tennessee law ‘regulates by drawing sex-based lines and declares that those lines are designed to encourage minors to appreciate their sex. . . The law restricts medical care only when provided to induce physical effects inconsistent with birth sex,’ she continued. ‘Someone assigned female at birth can’t receive medication to live as a male, but someone assigned male can.’”

“It would be a sad irony if the Supreme Court diminished the state’s ability to protect young people from potentially harmful medical treatments at the very moment when the efficacy of those treatments is subjected to an increasing amount of doubt. The risks of adverse side effects are quite plain and potentially severe. For example, a government expert admitted in a different case that puberty blockers can diminish fertility in adult patients, even after an adult has stopped their use. . . But attempting to protect children against the lifelong consequences of medical treatments administered before they’re old enough to fully understand the risks isn’t malicious. It’s a traditional function of American government.”

Because the transgender issue focuses on real people who have real struggles, this is a sensitive and very personal issue.  However, I believe what follows accurately summarizes what the Bible teaches:

1. Maleness and femaleness are God’s choice, determined at conception.  But growing into one’s masculinity or femininity and embracing it can be thwarted by cultural and family developments.  It seems reasonable to conclude that gender identity is a developmental issue.
2. It is certainly true that God desires that every male grow to masculinity and every female to femininity.  When that does not occur, the culture has developed labels such as transgendered and transsexual.  Regardless of the labels, God sees each individual as of worth and value because they bear His image, but as broken individuals.  As with every human being, the salvation offered in Jesus Christ heals the brokenness.
3. As with every individual human being, our fundamental identity is in Jesus Christ.  Much of the postmodern world has focused on sex or gender as the primary aspect of personal identity.  But the Bible calls on us to identity with Jesus—He is our core identity, regardless of whether we are male, female, transgender, etc.  Identity in Christ is a profound, transformative concept that results from placing our faith in Christ.
4. It is certainly true that God intends for males to manifest masculine characteristics and females to manifest female characteristics.  The fact that some people are born with evidence of mutations in sex-determining genes does not impact their value and worth to God.  But the Bible is clear that men are to appear as men and women as women (e.g., Deuteronomy 22:5).
5. Focus on the Family has published a helpful position paper of the transgender movement.  I quote several points from that paper:

• We must remember that those who struggle with their gender identity have lived lives of great pain, confusion and rejection . . . We must humbly share [God’s] love embodied in the Gospel, to lift them up in prayer and to allow the Holy Spirit to bring about conviction, healing and transformation.
• We affirm the Christian view that to be human is to be holistically united as body and spirit.  Often, transgender advocates hold to the pagan view that the body is a container that the spirit is poured into.  As such, they erroneously conclude that God has mistakenly put an opposite-gendered spirit into the wrong body or that the body is not the real person—that only the spirit is real.
• We call upon parents to take a positive role in their children’s development by providing them with a strong, Christian example of what it means to be male and female.
• We believe we are called to proclaim the truth and beauty of God’s design and the redemption from sexual brokenness in our lives and culture can only come through Jesus Christ.  Like everyone else, “transgendered” individuals are desperately in need of God’s truth and deserve to know the love and compassion of Christ as shown through His people.

May God, in His grace, empower the church to see transgendered people as they are to see every human being:  A broken sinner desperately in need of the salvation that Jesus offers.  As with all human beings, only in Christ is there healing, wholeness and the promise of a resurrected body after which the struggle with brokenness and sin will end.  In eternity there will be no struggle with identity or life’s meaning.  Both are fulfilled in Christ.

See The Economist (29 June 2024), p. 21; David French in the New York Times (9 December 2024); Focus on the Family Position Paper on Transgenderism at www.focusonthefamily.com; and “What is a Biblical View of Transgendered People” at www.probe.org.