This essay is an excerpt from Abigail Favale’s recently released book, The Genesis of Gender. It has been reprinted with permission from Ignatius Press. You can view Public Discourse‘s webinar discussion of the book here.

I have given birth four times. Five, if you include the tiny body, no longer living, that was released from my womb at only ten weeks. The other four pregnancies bloomed to full term, my body stretched by a cumbersome metamorphosis, in which I am the cocoon. After the baby comes, once the chrysalis opens to unveil the face of a new human being, I feel shipwrecked, flung onto the shore in a state of limp exhaustion, not by the sea, but by my own terrible undulations. Thus begins the long season of postpartum aftermath, a grueling stretch of time that no one really talks about, that never appears on screen and is etched on few pages.

After each of my births, there is a moment when I am able to hobble to the toilet on my own, a massive pad pressed between my legs to catch the gush of blood that comes when I stand upright. I have to shuffle past a mirror to get there, and I can’t help but look at the stranger I see, as if she is a monstrous Gorgon and I am trapped by her gaze. I see a body that doesn’t look like me, that never matches how I appear in dreams or my own mental image. She has a dazed, half-crazed look, like she’s just crawled out from the underworld; her breasts hang down, already beginning to harden with milk; her womb protrudes, emptied now but swollen nonetheless, as it will continue to be, for months. She fills me with disgust, that postpartum Medusa. She is grotesque and excessive, bleeding and leaking and saddled with flesh. I try to forget her, but she is there in every mirror, staring back at me when I expect to see myself.

With her comes a quiet terror that seeps slowly into my mind, like rising bathwater, until I’m submerged. Every sudden sound becomes a threat. Especially the crying—when the baby screams, I feel zaps of electricity in my brain, jolts of panic that sometimes get so bad I seek pain to release the tension, pricking the skin on my arm with a needle or stabbing my thigh with a key until it purples. Then my panic eases, giving way to a pervasive shame that irradiates my whole being like magma. There are moments of calm and even bliss, yes—but how quickly these can be shattered, how suddenly I can collapse into self-loathing and fear, how utterly this black flag can unfurl and block out the light.

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Even now, as I write this, almost nine months postpartum, I still can’t look at myself in the mirror without feeling disgust and a desire to punish my body, to starve it into submission.


In this state, my own mind becomes a predator. Thoughts invade my skull like a corkscrew, turning and turning until I can’t pull them out. They strike in moments of quiet, like during Mass, and instead of Christ in the elevated Host I’m seeing a gunman burst in from the back of the church, and everyone’s cowering under the pews, and I try to hide my baby, but he’s strapped to me and crying and the gunman can hear him, and there’s no way out; my flesh can’t stop the bullet that will pierce us both.

This is what it’s like for me, the aftermath of birth. Even now, as I write this, almost nine months postpartum, I still can’t look at myself in the mirror without feeling disgust and a desire to punish my body, to starve it into submission. When I get out of the bath, I stand off to the side, hiding from my own reflection. I never thought, until recently, to compare my postpartum body dysmorphia to gender dysphoria. I am not plagued by the desire to be a man, that’s true. Nonetheless, the more obviously female my body becomes, the more discomfort I feel. Post-maternity, I long to embody a fantasy of womanhood divorced from femaleness, a woman who is hard-bodied, straight-hipped, and unbreasted, whose womb is imperceptible, unassertive. Even while I enjoy the skin-to-skin intimacy of breastfeeding, my breasts feel like interlopers, artificial appendages.

The acuteness of the dualism I feel, the disintegrated sense of self, is not unlike the descriptions I have heard from women who have identified as trans at one point or another. I do not pretend that my experience gives me full insight into the transgender experience—it does not—but when I hear women talk about gender dysphoria, I feel an echo in myself, an inner voice that whispers, I know what that feels like. Unlike the dysphoria of many of these women, however, mine is an acutely postpartum phenomenon and, at least thus far, tends to resolve when I stop breastfeeding and my body deflates like a balloon. Accepting the truth and goodness of my femaleness does not immediately resolve episodes of bodily dysphoria, but it does, at least most of the time, keep me from self-harm.

It took years and multiple births to accept that my invasive thoughts and self-loathing were pathological, a clear sign of postpartum anxiety and depression. My first instinct was to resist the label, to power through on my own strength, teeth clenched. I hunkered down in an alcove of denial, shielding myself from reality—the reality of my maternal body and the reality of my mental illness.

Self-Harm as Self-Care

According to Laura Reynolds, a former trans-identified woman, the gender paradigm has “rebranded self-harm as self-care.” This is yet another contortion of language with devastating consequences. Clinical guidelines for gender dysphoria have shifted in recent years toward the affirmation model of care, which unquestioningly affirms a patient’s interpretation of his or her condition. This seems to be the lone corner of psychology where the typical approach to psychological distress is upended, where practitioners are encouraged to take a patient’s self-assessment at face value, rather than testing that assessment against reality.

What would it look like, I wonder, to take a so-called “affirmative” approach to my own mental illness? What would it sound like for a therapist to affirm my perception of reality? “Why yes, you should be hypervigilant at all times, especially during Mass, just in case a gunman shows up. You are in constant danger; your baby could die at any moment. Yes, your breasts aren’t really part of you since you feel so disconnected from them. In fact, you might consider amputating them, so your reflection doesn’t bother you anymore. And yes, if you feel like you are a terrible mother, I’m sure that you are.”

You may think I’m being flippant here, because those responses seem so absurd, the dire opposite of therapeutic. Yet when I listen to the stories of detransitioners, this is often how they describe their experiences with affirmative care. The affirming doctors and therapists do not explore other causes or potential solutions but send the patient straight down the medical transition track.

This seems to be the lone corner of psychology where the typical approach to psychological distress is upended, where practitioners are encouraged to take a patient’s self-assessment at face value, rather than testing that assessment against reality.


In story after story, I hear descriptions of complex mental distress that is attributed to a single source, gender, and “treated” through the unproven, catch-all solution of medical transition. I am not surprised that people latch onto the notion of transition as a panacea for all their problems. The idea of a straightforward and decisive solution to layers of psychological distress would be tantalizing to anyone. What’s surprising to me are the clinicians, thoughtlessly trotting down the affirmation route like lemmings, unconcerned by the lack of high-quality evidence justifying medicalization. The affirmation model departs from proven therapeutic approaches like cognitive behavioral therapy, which tests a patient’s perceptions against objective facts and evaluates cognitive distortions.

Gender dysphoria needs to be acknowledged and treated as a psychological illness. I understand the resistance to language of disorder and pathology, motivated by a fear that such language is stigmatizing. I understand, but I disagree. To reclassify disorder as order forecloses the possibility of recovery. I think of my own battles with anxiety, depression, self-harm. I don’t want someone telling me those things are normal and good. I want to be healed. I think of Jesus in the Gospels, healing people from all kinds of maladies. They cry out to him, reach for him, call upon him, potently aware of their need for healing. We should not resist the language of pathology here. What we must resist is the stigma, the othering, of those who struggle with mental illness. We should normalize the experience of this struggle, but not the illness itself. And when I speak of those who struggle, I include myself among them.

The affirmation model, while often motivated by good will, is ultimately unethical. It is dependent upon a diminished, dualistic model of personhood. The goodness, wholeness, and givenness of the body is discarded. The body is seen merely as an inert object, upon which an idealized sense of self is projected. This approach inverts the very definition of health, by pursuing a “treatment” that makes a healthy body ill, actively disrupting the delicate balance of the endocrine system in ways that have cascading and harmful effects. Invasive surgeries on healthy genitalia are often irreversible and involve short-term pain and long-term complications. The affirmation approach encourages violence to the healthy body rather than carefully working through the underlying causes of psychological distress and considering ways to manage that distress that do not cause physical harm. In this model, the body is the scapegoat, blamed as the sole source of one’s pain and sacrificed on the altar of self-will.

What would it look like to approach a person in the depth of his complexity? In the fullness of her dignity? Such an approach would first seek to understand whether the person is actually suffering from gender dysphoria or whether there is something else going on. Classically, gender dysphoria manifests in early childhood and, in the vast majority of cases, resolves through the process of puberty. In cases of late or sudden onset, it’s unlikely that there is an underlying neurological condition. I’ve heard stories from women who experienced childhood dysphoria and never transitioned; I’ve heard stories from girls who transitioned without experiencing true dysphoria. Even if there are patterns and mutual echoes among these stories, none are exactly alike. Each person must be approached in her unique situation.

When sexed identity is grounded in the body, rather than confined to stereotypical mimicry, we are freer to be who we are.


What would it look like to take concrete reality, especially the healthy body, seriously? To see the body as integral to the self? What would it look like to “test” a person’s assumptions against that reality, to lead him into a grounded consideration of material existence, rather than pretending that matter does not matter? What if we embraced this as a guiding principle: do not harm a healthy body?

What would it look like to gently question a patient’s assumptions about sex stereotypes rather than reinforce them? To encourage a healthy exploration of one’s distinctive personhood—to give a girl freedom to live out her girlness, and a boy his boyness, in a unique and unrepeatable way? This, too, is part of God’s creative vision. When sexed identity is grounded in the body, rather than confined to stereotypical mimicry, we are freer to be who we are.

A Longing for Wholeness

By now I’ve made it clear that I disagree with transgender anthropology, namely its denial of the sacramental principle that the body reveals the person. Nonetheless, in every desire can be found a desire for something good, even if that good desire becomes distorted or aimed at the wrong thing. Trans identities signal a longing for wholeness, for an integrated sense of self, in which the body does reveal the person. This desire is fundamentally a good one; it reflects the truth of the human being as a unity of body and soul. The error comes in thinking that this integration has to be achieved through artifice, through violence against the body, rather than recognizing that we are integrated by our very nature. The lie—I have to force my body to reveal my true self—supplants the truth: the body I am is always already revealing my personhood.

This enduring desire for integration and wholeness can be harnessed, I think, as a bridge from a dualistic anthropology to a holistic one: a bridge from self-rejection to self-acceptance. In many transition stories, I hear a fundamental desire to escape the self. The allure of transition is about not self-expression but self-destruction, and the creation of a new persona altogether. I can see how intoxicating this must be, especially to adolescents. How I would have leapt at the chance to be someone other than myself in the throes of teendom. My intermittent suicidal ideation as a teenager was not so much about the desire to be dead, but the desire to stop being me, to self-immolate and rise again like a phoenix.

The affirmation model cannot offer true self-acceptance, unless the body is no longer considered part of the self. Choosing a lifetime of medicalization in order to maintain an illusion of cross-sex identity is not “being who you really are.” The affirmation model is self-denial masquerading as self-acceptance. Because our bodies are ourselves, what is being “affirmed,” ultimately, is the patient’s self-hatred.