Quaeritur: Care of Transgender Patients (Part 1 of 2)

Recently a medical student emailed me a long and well-considered question.

I have a question regarding the care of transgender patients. Before I begin, I just want to say that I consider myself an orthodox, pro-life Catholic who is trying to follow Church teaching on this issue. I am not attempting to undermine Church teaching, and I do not want to be spreading heresy. Also, when I speak about transgender persons, I want to differentiate them from intersex persons (who actually do have ambiguous genitalia).

From what I have been reading about Church statements and Church teaching (from Pope Benedict and Pope Francis), there is a consistent condemnation of “gender theory”. This is something that I completely agree with. There is no such thing as “multiple genders” and those who claim there are are incorrect. During many of my LGBT lectures, they have included slides on how there are many different genders that someone can “define themselves” as. I think that for many people in the Church, this is what the transgender movement represents, and this is why there is such a strong backlash against many of its beliefs and ideas.

However, there are people suffering from gender dysphoria who are caught in the middle of this fight. Reading a lot of the stories of persons who really suffer from gender dysphoria breaks my heart. Many of these persons have co-morbid psychiatric illnesses, and many attempt and/or successfully commit suicide. They face a lot of abuse from family, friends, and sometimes Catholics/Christians. I didn’t provide the links with this email, but my understanding is that the current medical techniques to help some of these transgender patients are very effective for the majority of patients. Most transgender patients who undergo the hormone therapy and/or sex reassignment surgery really do experience psychological relief. I included a link here from a blog of a transgender Catholic who discusses Church teachings on this issue....

**Also, I want to clarify. My understanding is that most children who experience gender dysphoria grow out of it later in life, so if the Church were to approve of certain medical procedures, they would only apply to later in life.**

With all this being said, what do you think our role is as Catholics and healthcare providers for future transgender patients? Do you think it is ethical to help some, maybe not all, patients undergo hormone therapy? What about sex-reassignment surgery? Also, my understanding is that different transgender people cope in different ways. Some of them do not even want any medical interventions and prefer to cross-dress or just identify as the opposite gender, while some do have these interventions and then regret them in the future. The Catholic Church, from what I understand, does not have a clear teaching on this, but we are going to be in the front lines helping patients struggle with gender dysphoria.

This is a very important question. First, I am grateful that you are striving to be faithful to the truth and follow Church teaching. I understand that your questions is about persons who suffer from gender dysphoria (e.g. genetically XX individuals who feel male, or genetically XY individuals who feel female), not people who have physically ambiguous genitalia or people with SSA.

Let's clarify what Pope Benedict meant by "gender theory." In your email you define "gender theory" as the idea that there are multiple genders. (I'll stick with Benedict because he is a philosopher by training and was first among popes to articulate arguments about gender etc.) In his 2012 Christmas address, he used the word "theory" to describe the idea that our gender is not an innate property. The "theory" is that maleness and femaleness are not congenital, but societally or personally determined. I pasted the relevant paragraph from the address below my signature line for you. This means that what the Pope condemned is not only that male and female is binary (he states that this is a "duality" in the Christmas address); he also condemned that maleness and femaleness is something an individual can interpret or assign themselves. It's part of their nature and their nature does not lie. To make it very clear: the popes have said that we are born male or female, and that is our gender. Any distress we feel about our gender is a disorder.

I am not saying (and neither are the popes) that people suffering from gender dysphoria aren't suffering. They are, as you point out, in distress and sometimes constant revulsion, fear, or self-hatred. They do, as you point out, often suffer rejection and abuse from others. And they can experience psychological relief with transgender medical and surgical treatment.

Tell me what you think of this: the fact that someone is suffering and experiences relief after a certain therapy may not mean that the disorder causing the suffering should be treated that way. An easy example is elective abortion: it relieves the enormous distress of the threat to self and lifestyle that a mother-to-be faces, but it is not the right approach to that distress. If not all treatments that result in relief are the right treatments, then trans medicine and surgery may not be right for people with gender dysphoria. Indeed, many believe (as I do) that the right treatment for gender dysphoria is to dig to the root of the dysphoria and treat the cause (broken early relationships or abuse, self-hatred, misunderstanding of femininity or masculinity) as well as the co-morbid conditions (domestic violence, high risk sexual behaviors, mood disorders, substance abuse, etc).

The medical student sent me a response back, which is to follow in the next post.

Third party reproduction

About a year ago, a gestational carrier of twins was admitted to our antepartum wing. Her condition required a long-term stay and she was not in her home state. To make matters more complicated, the presenting twin was not vertex. There was heated disagreement between the intended parents and the gestational carrier about mode of delivery because my attendings recommended a cesarean section for the twins. The carrier did not want a C-section. The physicians' hands were tied: we couldn't do a C-section on a non-consenting woman without committing assault and battery. But the agreement signed (while not designed for this state) did specify that the gestational carrier was to comply with physician recommendations on mode of delivery.

To translate into colloquial terms: about a year ago, a surrogate carrying twins for a gay couple came to our hospital while out of her home state. Because the first twin was not head-down and for a few other reasons, my attendings recommended a C-section for delivery. There was a painful, days-long disagreement between the surrogate and the couple, because the surrogate didn't want to have a surgery. We couldn't do a C-section without the surrogate's consent, but the contract signed by the surrogate and the couple said we should have been able to. ("Surrogate" is not a term preferred by the ASRM or third party reproduction lawyers.)

The ethics committee was, as I recall, rather unhelpful. No member of the healthcare team ever saw the agreement signed between the intended mothers and the gestational carrier. All residents whose names were not already in the chart were encouraged not to open the chart or see the patient out of concern for legal repercussions. The intended mothers of the children became rather forceful, asking that the healthcare team discuss matters with them before discussing them with the patient and lurking around the floor to catch any healthcare providers who might be discussing the case of their children. When it once appeared that the twins might suffer some adverse neurologic outcomes because of the disagreement, one of the mothers stated she did not want the child if there was brain damage.

All of this was a rather unpleasant ethical case that ended as well as it could, since the gestational carrier agreed to a C-section eventually and both babies were born. I have many dissatisfied feelings about the way all five people's lives changed during this pregnancy episode. I began to wonder whether the true nature of things (a contract about goods belonging to the adults) came out in the unpleasantness.

Recently my program has been adding more IVF experience for us. A few months ago I drove out to the IVF clinic of the new professor we'll be working with. As luck would have it, there wasn't much on the schedule and I didn't have to explain much. Although I've written about being "inside IVF" before, this one afternoon included actual experience of ARTs (two IUIs and an embryo transfer). Since I know how these procedures are done, in a way it wasn't earth shattering. But in another way, it was painful. By the end of the morning I felt nauseous and had to talk aloud with the Lord in the car about the experience.

Unfortunately, this isn't the end of this topic. I haven't covered it much on my blog, as I've mostly focused on contraception and sterilization. But now that I'm becoming a third year resident, who will spend two consecutive months on the REI service, it will become a topic of much more discussion.