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Gender dysphoria: Some Catholic bioethical reflections


David Albert Jones offers some brief bioethical considerations relevant to the care and support of people with gender dysphoria. A pdf is available here.

Gender dysphoria: Some Catholic bioethical reflections

David Albert Jones

Gender dysphoria is commonly defined as “a condition where a person experiences discomfort or distress because there's a mismatch [or incongruence] between their biological sex and gender identity”. [1] Gender identity here refers to a person’s sense that he or she is male or female. [2]

Gender incongruence is no longer classified as a mental disorder but the associated distress, gender dysphoria, is a recognised psychiatric diagnosis. Gender dysphoria is also associated with an increased incidence of other mental health problems and with a greatly increased risk of suicide.

Catholic bioethical analysis should always fully recognise the suffering experienced by people with gender dysphoria and by those close to them. “First of all it must be stated that this is a matter of true infirmity, and therefore in whatever circumstances and degree of infirmity the patient finds himself, he is to be treated as a sick person who requires care and the utmost charity.” [3]

There are different psychological theories of gender identity. It is disputed how far gender identity is shaped by upbringing and by social and cultural factors. Unfortunately, it is increasingly difficult to assess the scientific evidence for different theories as the academic debate is increasingly politicised.

Different theories of gender identity may also presuppose different philosophies or ideologies of gender, some of which are incompatible with a Catholic understanding of the human person. For example, the Church teaches that the body is a gift from God and that the sexual characteristics of the body are to be accepted, cared for, and respected. [4] The body is part of the person, it is not separate from who we are. In contrast, it is a philosophical mistake to think that our sex is something “that we choose for ourselves” [5] or that a transsexual person literally “changes sex” when he or she undergoes surgery.

The social transition that some transsexual or transgender people make, from living as one gender to living as another, may involve changing their physical appearance but it does not change a person’s sex. A person’s biological sex remains the same and retains its own significance. This should not be denied and sometimes should be acknowledged overtly, especially in a healthcare context.

The biological sex of a person is also an essential element in the Catholic understanding of marriage and hence of sexual ethics. The union of a trans-woman (a male-to-female transsexual) and a man is thus regarded by the Church as a same-sex union. The Catholic Church does not recognise as a valid marriage a civil union between people of the same biological sex.

In relation to the ethics of surgery, the Catholic ethical tradition holds that destruction of a part or function of the body is morally acceptable only when it directly benefits the health of the person as a whole (or at least, does not involve permanent harm). This is termed the “principle of totality”. [6] On this principle, forms of gender reassignment surgery that destroy sexual or reproductive function, such as genital “reconstruction”, hysterectomy, and double mastectomy, are unjustifiable. Such surgery does immediate harm to the body of the patient while the hoped for social or psychological benefits are indirect and uncertain.

Hormonal interventions and cosmetic procedures undertaken in the context of gender reassignment (breast enlargement for example) may not irreversibly destroy function. However, they are open to other ethical objections, for example where they are elements in a larger project that also involves commitment to more drastic surgery. Some professionals also question the evidence base for these interventions or consider them a technical “fix” for personal and societal issues.

One area where hormone therapy should have no place is in the treatment of children with gender incongruent feelings or suspected gender dysphoria. It is widely accepted that, in most instances, such feelings do not persist into adulthood. Furthermore, minors are not well placed to give informed consent to interventions that could affect their long-term sexual and reproductive health.

Gender identity clinics in the NHS do not prescribe cross-hormone therapy in minors but they sometimes prescribe hormone analogues to suppress puberty. The aim is to “delay potentially distressing physical changes caused by their body becoming even more like that of their biological sex” [1] and hence to delay decisions about more drastic measures until the child reaches adulthood. However, while often turbulent and always challenging, puberty is a healthy part of physical and emotional development. Suppressing puberty is a drastic intervention. It deprives someone of an important stage of personal development and begs the question as to the person’s mature identity.

The best approach to the treatment of minors with gender dysphoria is for them to “receive support to help them cope with the emotional distress of the condition, without rushing into more drastic treatments.” [1] In practice, the ethics of this approach will depend crucially on the nature of the support that is provided. The first option for psychological support should involve the whole family.

It should be noted that in English law it is not necessary to undergo surgery in order to obtain a Gender Recognition Certificate. The process of transitioning is thus not one simple step but several steps. Persons with gender dysphoria who wish to express their sense of gender identity are not necessarily committing themselves to legal transition, or to marriage in the “acquired gender”, or to surgery, or even to hormone treatment. These are, or can be, distinct decisions.

It must also be recognised that the suffering of people with gender dysphoria can be exacerbated by stigma, bullying, or social exclusion. The Church therefore needs to develop a pastoral approach to the care of people with gender dysphoria, one that effectively communicates “the depth of God’s love for them and their intrinsic worth and beauty”. [7] This is important in particular for children who “should always be and feel safe and secure and know they are loved.” [7]

Abstracting from issues of marriage, sexual ethics in a narrow sense, and surgery that destroys sexual or reproductive function, there is no consensus among Catholic moral theologians as to whether an adult who transitions is thereby departing from Catholic moral teaching. Some argue that a person’s attempt (which may not be culpable) permanently to “mask” his or her biological sex is presumptively at very least a morally misguided choice, with which it is wrong to collude. Is it really beneficial to reinforce a person’s false beliefs? Others regard the adopting of an opposite gender role as in principle morally permissible, if it can ameliorate an otherwise severely distressing condition, “easing [their] social life” so that “they can live as belonging to their acquired gender”. [8]

Notes

1 http://www.nhs.uk/Conditions/Gender-dysphoria/Pages/Treatment.aspx
2 Or both, or neither, or something in between, but gender identity always relates to maleness or femaleness.
3 U. Navarrete, “Transsexualism and the Canonical Order,” NCBQ 14.1 (Spring 2014): 105–118, p. 115.
4 Pope Francis Laudato Si para. 155 https://laudatosi.com/watch
5 Pope Benedict XVI, ‘Address to the Roman Curia’ 22 December 2008.
6 Pope Pius XII ‘Address to the First International Congress on the Histopathology of the Nervous System’ 14 September 1952, paras 13, 34-35; G. Kelly, ‘The morality of mutilation’ Theological Studies 17 (1956): 322-344.
7 USCCB Chairmen Respond To Administration’s New Guidance Letter On Title IX Application May 16, 2016 http://www.usccb.org/news/2016/16-056.cfm
8 CBCEW Briefing Note on the Gender Recognition Bill from a Catholic Perspective 8 January 2004, para 11. http://www.catholic-ew.org.uk/content/download/22490/143789/file/0401- _CBCEW_Briefing_Note_on_the_Gender_Recognition_Bill_from.doc