Quaeritur: Postpartum LARCs and mental illness

I was recently asked:

I recently looked up your article about encouraging a LARC for a drug addicted patient and your subsequent examination of conscience. I have a 27yo G2P1 bipolar patient with current benzo/meth/etc addiction who's 32 weeks and planning on getting a tubal ligation. I did not disagree with her decision, and was considering the morality of this. Did you ever find a conclusion to this "absurd state" of using contraception for those in addiction or mentally impaired patients (mental retardation, schizophrenia, etc)? Did you find any Catholic discussion regarding this? Humane Vitae and the discussion in Catholic Health Care Ethics book all are geared towards a typical person.

 Okay, let's take this apart. I want to say first that I did not encourage that patient in my blog post down any particular path. I never discussed postpartum family planning with her because we were always trying to ground her in the reality of her pregnancy and in circumstances surrounding her safety. It was only after my attending made a comment about contraception and I went to a St. Louis CMA guild event on LARCs in the mentally handicapped that I started to think about HV's possible limitations. (There's a post about that one, too, which you've probably seen.)

There is no good answer that I can find on this issue. The best that we came to at the guild event was temporary sterilization with filshie clips, but the Church is clear that not even temporary sterilization is acceptable. There are a few sets of articles from the Linacre that touch on it (from most to least relevant):

The articles that overtly deal with contraception in the mentally disabled adult or adolescent:

• Contraception for the Mentally Disabled: A Contraceptive Act? (Napier, 2013)This paper argues that in certain circumstances, a Catholic institution that cares for disabled persons can ensure that some of them conform to a temporary sterilizing intervention. The argument proceeds by observing that the Church permits temporary sterilizing interventions for rape victims, because such interventions are not contraceptive acts, but rather, acts of defense. For similar reasons, some mentally disabled persons cannot consent to sexual intercourse and since rape is defined as unconsensual intercourse, some mentally disabled persons are proper candidates of temporary sterilizing interventions. These interventions do not count as contraceptive acts either. This is the case even if the disabled person in question desires the intercourse. This is so because consent is an intellectual act and desire is a passion. Desire does not entail consent. Although the conclusion reached may look "liberal" or "heretical" the argument shows that it is consistent with firm Church teaching.
• The demands of human dignity: Sexuality in the young person with intellectual disabilities (Fernandes, 2014)The topic of sexuality among the disabled is often ignored within Catholic seminaries; within pediatrics, it is treated as a “problem” where the best solution is contraception or sterilization. In this article, the authors argue for an approach to sexuality in disabled youth that is grounded in the inherent dignity of the person, borne out of Christ's own humanity. Because sexuality is a part of the human person in his or her totality, it cannot be ignored or obscured; on the other hand, it cannot also be the overriding “problem” which defines them. Rather, by friendship, love, and covenantal solidarity with the disabled person, we can begin to set an example for them and for society that there are goods to be strived for beyond the physical. The demands of dignity require practical changes in seminary and medical education and practice.
• Contraceptives for Victims of Rape and for the Mentally Disabled: A Reply to Stephen Napier (Tollefson 2013)In this paper I argue for the following claims. First, contraceptive acts are intrinsically wrong, and not merely always wrong within the marital context. Second, in consequence, the defense of the administration of contraceptives in case of rape must be understood under the rubric of the principle of double effect. Third, the existence or threat of rape is therefore not a sufficient condition for the permissible administration of contraceptives; the intention must be upright. Fourth, in the case as described by Stephen Napier, the intention with which contraceptives would be administered is almost certainly contraceptive; thus this administration would be an instance of an intrinsically evil act. Recognition of why this is so is the key to understanding why, despite a prima facie agreement, as noted by Napier, between his own position and that of Germain Grisez, there is nevertheless a rather deep disagreement. I articulate that disagreement, and indicate why I believe the question has not been fully resolved by Napier's essay.

The use of hormones in sexually active patients

• No Justification for Using IUD to Treat Menorrhagia (Raviele)
• The Mirena® Levonorgestral-Releasing Intrauterine System and Its Application to the Treatment of Menorrhagia: A Moral Opinion (Mulligan)
• Levonorgestrel in cases of rape: How does it work? (Raviele 2014)
• Does levonorgestrel emergency contraceptive have a post-fertilization effect? A review of its mechanism of action (Peck et al, 2016)
• Mechanism of action of levonorgestrel emergency contraception (Kahlenborn et al, 2014)
• Appreciation for analysis of how levonorgestrel works and reservations with the use of meloxicam as emergency contraception (Schneider et al, 2016)

The HIV/condom debate

• “Validity” and “liceity” in conjugal acts: A reply to Stephen Napier on the HIV-condom debate (Arias)
• Condoms and HIV: The State of the Debate (Newton)
• The Missing Premise in the HIV-Condom Debate (Napier)
• Condoms and AIDS: Is the Pope Right or Just "Horrifically Ignorant"? (Wills)

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Question used with permission.

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

This post is a continuation of a conversation about Catholic teaching applied to transition for transgender patients. A medical student asked whether gender dysphoria could licitly be relieved with medical and surgical therapies. Following my reply, the student wrote back. I'm going to interject my responses outside of the block-quoted text from the student.

My initial reaction is that I completely agree with your succinct assessment: “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.” My thought is that for the vast majority of us, this is a clear cut statement. For persons with intersex conditions (and I would add transgender as well), they suffer from a disorder.

I’m going to take intersex cases an example before approaching transgender persons: Some of them are born with ambiguous genitalia and chromosomes. Determining their correct gender is a difficult clinical task involving input from the physicians, parents, and children. I’m sure that Pope Benedict would probably agree that due to the brokenness of the human condition, persons are sometimes born with mixed features from both genders. The existence of intersex persons doesn’t disprove or say anything about Catholic teaching regarding sex and gender, it just confirms for us that we live in a fallen world. Another analogy would be that persons are born with down syndrome, schizophrenia, and many other illnesses that impair intellectual capacity. The existence of these persons obviously does not disprove the existence of the “intellect” or the “will” that human beings, as rational animals, possess. These cases are just more examples of the brokenness of the human condition in our fallen world.

I think (hope?) that the above paragraph isn’t particularly controversial. I’m sure that most Catholic theologians would probably agree with my statements.

"Intersex" is a colloquial term, not a medical one. In medicine we refer to people with ambiguous genitalia, and I think that's more helpful in this discussion, because it's only a physical (and pretty external) defect. "Intersex" is a more emotive term that tends to lead the hearer to believe in a spectrum. Since I know that sex is binary, I find it an unhelpful term, much like "gender-fluid" or "bisexual." These terms refer to things that exist (e.g. a woman who has periods in life or even periods during the day in which she feels more like a man, or a man who finds himself attracted to men and women), but the words themselves tend to make us think of reality wrong. Words should help reveal the way things are; doubtless, many people today believe that "intersex" and "bisexual" reveal the way things are, but since we believe that humans are male or female, I would disagree. I don't mean to be picky, but I do want to draw your attention to the use of a term that is non-medical and possibly unhelpful. I agree, however, that persons with ambiguous genitalia do not prove that sex is non-binary.

I’m going to (try) to apply the same principles to some (maybe not all) persons that identify as transgender. My understanding is that the current scientific theory about gender dysphoria is called the “brain sex” theory. Essentially, it confirms what we Catholics have been saying for a while: Sex and gender are deeply ingrained properties of the human experience. They are the result of many neurological and hormonal puzzle pieces that have to fall into place during development. For most people, all the puzzle pieces align and our biological sex and neurological sex are congruent. Most males feel as though they are male, and most females feel as though they are female. However, like most of human development, there are many other environmental factors that come into play. I am sure, as you have pointed out, that for transgender patients, the experiences of "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)” are all contributing factors into why they experience gender dysphoria. So, my conclusion is that for these people, they really do have a physiological justification for why their body does not feel right for them. They have a mismatch between their neurological sex and their biological sex.

I think this is likely correct, although the lines between neurological and psychological are difficult to pin down.

Now, this doesn’t necessarily justify any of the treatments or therapies I will describe below for this disorder, but I think that it makes an argument for why these persons may have a biological/neurological basis for their gender dysphoria. I have heard some relatively influential Catholic commentators use the term “gnostic” to describe these persons, and I really do think that this could be a mischaracterization of the conditions these persons face.

I don't understand why people use the term "gnostic."

So, moving on to therapies for gender dysphoria. I completely agree with you that these patients probably do need therapy to help them with: "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)”. However, and I certainly do not consider myself an expert in this vast and complex field, but my understanding is that there is little evidence that these reparative therapies for gender dysphoria actually work. From my understanding, the APA and American Academy of Pediatrics appear to be against using reparative therapies. Now, certainly, there is a political agenda with these groups and they are fallible organizations, but they are the experts in these fields and I haven’t found any convincing studies that would tell me why I should ignore their advice on these matters (if you know any, please shoot them my way!).

Finally, with regards to some of the more “dramatic” and irreversible therapies such as sex reassignment surgery and/or hormone therapy, my initial thought is that they would be similar to a preventative mastectomy/hysterectomy. The intent would be to relieve the patient of their severe mental suffering, and the sterilization would be the secondary effect in this case. I know that my thinking here is not as clear, but I don’t know if I necessarily agree with the comparison to elective abortion. Elective abortion is a grave evil precisely because it destroys a human life, which has infinite human dignity. There has been crystal clear teaching on this issue throughout Church history, beginning with the Didache. However, with regards to persons suffering from gender dysphoria, I sort of see this an attempt to help relieve them in some way of a neurological/biological mismatch that they are experiencing between their physical appearance and inward state. I sort of see it as a last ditch effort which does have proven clinical efficacy. I don’t like the fact that these patients have to mutilate themselves and recreate their bodies according to their “neurological sex", but I haven’t seen any therapies that are more effective.

Now some clarification: I am not a proponent of reparative therapy, which I understand to be largely in reference to people with SSA. SSA is just a desire and is not a sin, and reparative therapy is not the answer that the Catholic church extends. Unfortunately, many other Christian denominations with less philosophical patrimony, don't understand this yet. My hope is that they can, and the strange well-meaning punishment of people with SSA can stop.

If you're extending the concept of reparative therapy to those with gender dysphoria, you might be referring to therapists who don't help them through "transition" to the other sex. These therapists might try to redirect the person to their biologic sex or (dishonestly) promise transition therapies initially and put up walls, never intending to fulfill their promise. Before I go further, is this what you are referring to? I ask because I've never heard anyone refer to refusal-to-transition as reparative therapy.

I guess to put my point bluntly, I am wondering if (some, maybe not all) persons who identify as transgender could be allowed to undergo the sex-reassignment surgery and/or hormone therapy to relieve them of their distress? It seems to be clinically efficacious. I guess all the long emails before that were trying to justify why I reached this point. I know that this is definitely risky, uncharted territory in terms of Church ethics, which is why I was trying to use analogies to persons with ambiguous genitalia and down syndrome. If I am wrong, could you explain to me why? I am not trying to go against the Church’s teaching, and I also want to help these people and do what is best for them.

I and many theologians would bluntly reply that no persons who identify as transgender should be allowed to undergo sex-reassingment surgery or hormone therapy. Very bluntly: these patients' comorbidities should be managed and they should undergo significant psychotherapy for their dysphoria. Like other patients who are deeply uncomfortable with aspects of themselves (DID patients, body dysmorphic disorders), they should be helped to understand who they were created to be.

Here is my explanation for why. Our gender/sex is sacred and is inseparable from our soul. It's part of the way God makes us to be saints. Men and women are irretrievably different in ways we can only clumsily understand. Philosophers have tried and failed many times to identify what category of quality "gender" is. Poets and thinkers have tried to articulate what "masculinity" and "femininity" are but only come up with generalizations and analogies. This is a hard thing to understand! It's no surprise that people think that gender is something we decide on.

The same thing happened with sex and procreation in the 1960s, when Pope Pius VI commissioned faithful Catholics like yourself to research the idea of birth control. The so-called "birth control commission" concluded that our fertility is something we should manage rationally, like we do every other aspect of our lives. There were parts of the physical universe (chemicals/hormones) that we could use as sons of Adam to change our lives. Shouldn't we do this?

It is hard to see the truth: gender, sex, and fertility are sacred ground because they more than anything in the physical universe are signs of who God is and are avenues to make saints. Luckily Pope Pius saw the truth about contraception in 1968. I think you and I are called to see the truth about gender now. It can seem like a big "no," but just like contraception/NFP, it's a strange and important "yes."