Elliott Louis Bedford, Ph.D.
System Director, Ethics
St. Vincent Health
Indianapolis
[email protected]

Jason T. Eberl, Ph.D.
Semler Endowed Chair for Medical Ethics
Marian University
Indianapolis
[email protected]

Introduction
The recent articles by Bayley, Gremmels, and FitzGerald touch on a timely issue.¹ While such articles focused on narrow methodological issues, we intend to examine relevant questions about anthropology. To develop this insight, we build upon traditional and recent magisterial teaching, as it is informed by Thomistic philosophy, and juxtapose the conditions known as transgenderism with disorders of sex development. To conclude, we draw some preliminary implications such discussion has for properly distinguishing and specifying the moral object of genital surgeries in each context.

Conceptual and Linguistic Precision
Because precision of language is so important in emerging issues, we will begin by addressing some terminological points to help structure the dialogue among Catholic moral theologians and ethicists.

First, it is now common to distinguish conceptually between sex, which refers to the biological/anatomical characteristics of being male or female based on one's chromosomal identity, and gender, which refers to the perception of being male or female typically as it relates to socially defined roles usually ascribed to a particular sex.² Such conceptual differentiation does not mean that the two are unrelated or have some intrinsic connectivity, whether practically or theoretically. To assume otherwise is to beg a central question at issue.³ At the same time, even a cursory review of the literature reveals the terms are often used interchangeably, if not equivocally.⁴ Our commentary will strive to maintain a balance which recognizes that distinction does not entail disconnection.

Second, the term "transgender" (TG) refers to "persons whose gender identity, gender expression or behavior does not conform to that typically associated with the sex to which they were assigned at birth."⁵ Previously this condition was recognized with a clinical diagnosis of "gender identity disorder." The diagnostic term now favored by the DSM-V, "gender dysphoria," denotes not only differing gender identification but also consequent significant feelings of distress.⁶ TG is therefore not reducible to gender dysphoria — since not all persons with differing gender identification experience distress about this perception — and one need not experience distress to seek out hormonal or surgical interventions. It is notable that the linguistic and diagnostic shift emphasizes the assertion that distress is the problematic phenomenon, not the self-identified incongruence between sex and gender.⁷

Third, disorders of sex development (DSD) are categorically distinct from transgenderism. Also known as "intersex" conditions, DSD are "defined by congenital conditions in which development of chromosomal, gonadal, or anatomic sex is atypical."⁸ Lack of a DSD is, in fact, one of the diagnostic exclusion criteria in a differential diagnosis for gender dysphoria.⁹

In sum, while sex and gender may be conceptually distinct, they are not necessarily practically disconnected. Similarly, TG and DSD are conceptually and clinically distinct, though both touch on the relationship between sex and self. These phenomena each raise important practical questions around the best way to provide a loving, healing, personal response to persons with these conditions in line with the pastoral approach affirmed by Pope Francis.¹⁰ Yet, we can only start to develop answers to these questions when we explore these distinct conditions in light of the anthropological insight found in church teaching.

Basic Christian Anthropology
Implicitly or explicitly, all Christian moral theology is grounded in a theological anthropology that is itself informed by a philosophical anthropology. The latter provides a framework for formulating a perspective on questions related to transgenderism that is not uniquely Christian and thereby debatable within the public square. As "a sure norm," the Catechism of the Catholic Church no. 355 outlines four basic components of an authentically Christian anthropology: Human beings occupy "a unique place in creation" as 1) created "in the image of God;" 2) in our nature uniting "the spiritual and material worlds"; 3) created "male and female"; and 4) established by God in "friendship." These form the bones from which our faith understands human beings and our essential nature. Each of the points, moreover, may be supported to a certain extent through philosophical argument. For instance, the first and final points affirm the philosophical insight that all human beings share equally in a common human nature. This common nature provides the ground for the moral requirement to recognize and respect all human persons, regardless of gender identity, as divinely created for the purpose of attaining loving union with their Creator.

The second and third points establish certain constitutive elements of this received human nature. Rejecting the extremes of reductionist materialism and substance dualism, these points affirm the view set forth by Thomas Aquinas (c. 1225-1274) that human beings exist as composite unities of an immaterial soul informing matter to compose a living, sentient, social, and rational animal;¹¹ and, by virtue of our animal nature, we are essentially sexed beings. However, by virtue of our essentially integral nature as a body-soul unity (corpore et anima unus), saying that one's sex is determined by one's animal nature is not to say that one is male or female only at the physical level. For, once God infuses a rational soul into a properly formed human body,¹² the body being the principle of the soul's individuation as well as of its sex, the soul now carries that individuality and sex with it as an "inseparable accident" insofar as it is the form of its particular body.¹³ It serves as the "blueprint" for its body such that one's resurrected body will be properly his or hers, including with respect to its sex.¹⁴ As John Grabowski summarizes, "sexual difference is accidental on the level of human nature but essential to actually existing persons."¹⁵ Therefore, the living material body, which is the human being, is constituted with inherent meaning and this meaningfulness encompasses and is manifested through our biological sex.

Moving beyond philosophy, but not contrary to a philosophical understanding of God as one divine substance, Christian systematic theology posits that human beings mirror the divine Trinity. That is, human bodily existence is primarily personal and relational with respect to God, other persons, and creation.¹⁶ Our personal sexed nature is also inherently dispositive towards God's ongoing creative act through our sexual complementarity. Hence, the Catechism no. 2360 states: "sexuality is ordered [per se] to the conjugal love of man and woman." In sum, sex is per se an inherent, ineradicable, given, and dispositive feature of actual human beings. Yet, this point does nothing to rule out a per accidens reality that sexed bodies might have developmental disorders or that we may not fully understand an individual person's sex.

The Catechism, as noted above, characterizes human beings as uniting "the spiritual and material worlds." While there are myriad ways of specifying the relation of "spirit" and "matter" in composing human nature, the church's magisterium and moral tradition have generally affirmed the Thomistic thesis that human beings are essentially "rational animals" comprising a material body informed by a rational soul (Catechism no. 365, citing the Council of Vienne (1312)). While strictly speaking the soul, which is immaterial, is not sexed, each soul is created by God as the vivifying principle of sexed bodies and is thereby individuated and sexed as an inseparable accidental quality of the human being. In short, as the vivifying principle of actually existing human beings, the human soul is properly characterized as sexed.

If the soul is sexed, is it also gendered? Thomistic anthropology provides reasons to consider the soul as also taking on gender as an inseparable accidental quality that continues to inform a person's psychological orientation after death. According to Aquinas, a human soul persists beyond its body's death by virtue of its immaterial intellectual and volitional powers. These powers are present as active potentialities from the moment a rationally ensouled human being comes into existence; their actualization, however, develops over time and is informed by the various intellectual and moral inclinations that Aquinas, following Aristotle, terms "virtues" and "vices" — e.g., wisdom, prudence, fortitude, etc.¹⁷ These virtues, once cultivated through habit, as influenced by one's social environment and pattern of free choices — or sometimes directly infused by God — become defining features of one's intellectual and moral character; as such, they can only be removed with difficulty,¹⁸ and, upon death, persist as indelible marks of one's soul.¹⁹

Insofar as one's social milieu plays an essential role in shaping his or her character, combined with the fact that one inherently relates to other persons in terms of his or her gender, it is reasonable to conclude that the indelible stamp of intellectual and moral traits definitive of a person's self-identity also includes their gender-identification. Furthermore, one's soul also retains self-consciousness — i.e., a person's unique first-person perspective²⁰ — and the intellectual knowledge one had acquired throughout life.²¹ All of these psychological traits, combined with the indelibly "sexed" quality of one's soul, support the thesis that one's soul becomes, and persists beyond death through resurrection, as "gendered." To assert otherwise is to bifurcate the essential integral nature of our body-soul unity, laying the foundation for a problematic body-self dualism, which we will discuss later.

This thesis supports our view that sex and gender are conceptually distinct, yet inherently connected. As Charlotte Witt contends, gender is uniessential to one's identity as a "social individual" that is, in her view, ontologically distinct due to its foundation in interpersonal relationships, yet grounded in one's existence as both a person and a human organism. She contends that, while transgender individuals may alter their identities as social individuals, they would persist as the same persons and organisms.²²

While we reject Witt's ontological separation of one's identity as a social individual, we affirm that one's gender is largely grounded in one's relational identity with other persons, though also inherently informed by one's biological make-up since others relate to us largely due to our apparent physical sex. Since, for Aquinas, one's soul is both the ground of one's psychological traits — including self-consciousness, intellectual knowledge, and virtues or vices — and the form of one's physical body, it follows that one's soul is both sexed and gendered.

Comparing Disorders of Sex Development and Transgenderism
These basic Christian anthropological assumptions allow us to contrast the phenomena of DSD and TG. This juxtaposition will provide a framework for offering an ethical analysis of specific interventions.

First, neither DSD nor TG is incongruent with Christian tenets about the origin, moral dignity, and final end of persons with these conditions. All are created children of the one God, share the same irreducible moral status, and are called to eternal life. How these conditions relate to our bodily, sexed life requires further articulation.

We believe that DSD does nothing to challenge or repudiate the essence of the anthropology outlined above.²³ The questions raised by persons with DSD take the embodied nature of human persons very seriously and thus are not inherently adhering to a problematic "body-self dualism."²⁴ The question this situation presents is objective and ontological: it is not a question about how one perceives themselves, but what sex the person actually is, given that the biological data might not offer certitude, especially given the variety of intersex conditions that may lead not only to ambiguity in one's external genitalia but also more subtle variations at the less readily observable hormonal level.²⁵ Thus, DSD does not repudiate a binary of sexual complementarity insofar as the question at hand is not whether there are more than two sexes or a spectrum of sexual identity; indeed these conditions are only intelligible in light of a male-female sex binary. Rather, they show that per accidens there is variation in the degrees and types of biological development within the categories of male and female. Further, the moral message of the Intersex Society of North America (ISNA) and Catholic authors like Erik Lenhart is that surgery ought not be forced upon individuals with these conditions, especially children who are unable to consent for themselves.²⁶

TG differs from DSD, however, by being premised on a discrepancy between the perceiving mind and the existing body — a body-self dualism. Consider how one transgender writer, Anna Magdalena, describes the situation: "for many transsexuals the site of gender embattlement is their subconscious sex, which is often confused with gender identity. Subconscious sex is a person's persistent embodied sense of belonging to one sex or another. It is not how one chooses to identify, but how one experiences oneself."²⁷ Subconscious sex is reportedly confronted and experienced as a given, not simply an option with which one chooses to identify. Magdalena then associates "subconscious sex" with the disputed concept of "brain sex" — i.e., the biological constitution and disposition of the brain as it has developed under the influence of hormones and other biological factors.²⁸ Hence, a conflict is perceived when subconscious sex is misaligned with genital morphology, which is also confronted as a given. Incongruity between these two perceived "givens" leads to distress and sets the context and impetus for surgery. Thus, gender dysphoria results in a perceived "war" between the brain and the genitals.²⁹ "Genital surgery," Magdalena writes, "cures ONE problem: the discordance between the brain and the genitals. It does nothing else [e.g., cure psychological comorbidities such as depression], and shouldn't be expected to do anything else."³⁰ However, the effectiveness of genital reconfiguration interventions to ameliorate adequately gender dysphoria, and especially associated psychological comorbidities, has long be been a source of dispute.³¹

Genital reconfiguration does not necessarily cure either gender dysphoria (distress), transgender identification, or alter the person's "brain sex." Indeed, some transgender proponents affirm that such interventions do nothing to change biological sex: "I am not female nor ever will be. I am a simulation of the female form."³² However, the more fundamental issue is the evident body-self dualism, that the "real" self is not the body as given but merely the "self" as perceived. The discordance, then, is primarily epistemic in nature. Surgical intervention thus involves manipulating the body to align with one's subjective self-perception. Admittedly, the lived experience of transgender individuals is a critical factor in the exploration of questions regarding gender identity. We must be cautious, however, in not putting total stake in self-perception alone, as subjective experience is not always the best indicator of what is truly the case — e.g., a schizophrenic patient may believe without any doubt whatsoever that they are talking with another person who, in reality, is not present; or, more closely analogous to the present case, someone with body dysmorphic disorder may feel like they should be an amputee, but most surgeons would not amputate someone's arm solely for that reason.³³

Conclusion: Towards Specifying a Moral Object
Having established elements of a basic philosophical and theological anthropology, it is now possible to offer some reflections on points necessary for moral analysis. The first point is that human moral equality does not necessarily mandate uniform treatment. In fact, equity of care requires that we respond to each case based on its own merits. Conceptually and clinically, DSD and TG are distinct phenomena; the surgical and hormonal interventions that might be licitly used in each case therefore also differ in kind.³⁴ Due to space constraints, and given that "bottom surgeries" would seem to carry greater moral gravity due to entailing the permanent radical alteration of a non-life-threatening healthy procreative organ and its sterilizing effects, we will focus on genital/reproductive organ surgical interventions.

First, DSD surgeries seem to take seriously the composite nature of human beings. For instance, the premise of such surgeries seems to be that, while as animals our anatomy and physiology typically develop toward their teleologic ends (e.g., eating, moving, reproducing), per accidens, there is: 1) a degree of variation within the category of what is biologically typical; and 2) a chance the body might develop atypically, i.e. outside of the general spectrum within a given category. Hence, DSD does not comprise an incongruity with one's "authentic" self or imply that one's soul is not properly informing their body, but rather that one's body has developed in a species-atypical way. The immediate end, then, of such surgeries is to correct atypically developed anatomy.

Second, while one might claim that the ultimate end of TG surgeries is body-soul integrity, the immediate end of such surgeries seems to be inescapably premised upon and reinforces a form of body-self dualism. For instance, a Cartesian analysis might claim that TG surgery conforms the body to the soul, positing that the "real" person is the soul.³⁵ This substance dualism, as we have noted above, is incompatible with a Christian anthropology and so is any justification built upon it.

Conversely, a reductive materialist analysis might claim that the surgery aligns the sex of the genitals with the gender of the brain.³⁶ But this argument presumes that such a duality does, in fact, exist and that the proposed intervention actually ameliorates the duality. Hence, unless there is some yet to be discovered scientific evidence to the contrary, it is doubly incongruent with a Christian anthropology, since the accidental exposure or lack of exposure of the brain to particular hormones does not entail a change in the essential nature of a particular animal or one of their parts (organs). Thus, even if the "brain-sex" hypothesis that exposure of the developing brain to certain hormones is a contributing factor to cross-gender identification is validated, it cannot be said that such exposure causes a change in the essential nature of the person.

Further, to argue that genital reconfiguration helps align or integrate a person as a composite being, one must deny at least one of the following tenets of Thomistic hylomorphism upon which Christian anthropology has been authoritatively based since the Council of Vienne: 1) that the soul is simple and not comprised of parts (e.g., the part informing the brain is female while that informing the genitals is male), or 2) an organ of a live human being that is typically developed (even those atypically developed) and functional is not properly informed by a human soul. In short, to argue that TG surgery integrates a human person, one must presume that the alleged ontological dis-integrity actually exists. The strong thrust of the Catholic philosophical tradition indicates this is not plausible; the dis-integration lies elsewhere, not on the level of ontology, and at present there is no evidence of a biological dis-integration. To summarize, it is implausible to affirm that the immediate end of these interventions is bodily (i.e., personal) integration. It seems rather to be the reconfiguration of typically developed anatomy.

This conclusion calls for a more refined analysis of the applicability of principles invoked by Bayley and Gremmels in their reflections on surgical interventions for transgender individuals: double-effect and totality, respectively. For double-effect is applicable only if an act's immediate end is good or at least morally neutral, and this is precisely what has not heretofore been demonstrated. Further, reconfiguring typically developed and functioning anatomy cannot be construed as either unless, perhaps, the principle of totality is invoked to justify the sacrifice of one part of the body for the sake of the well-being of the whole person. Our analysis calls this latter claim into question, as we have argued that transgender individuals are not experiencing an ontological dis-integration, even if they perceive themselves to be. Consequently, the object of the act of such surgeries could not be described as integrating the person as a body-soul composite.

In sum, our anthropological analysis aims to help theologians and ethicists gain clarity in precisely defining the moral object of genital surgeries, particularly in the context of TG. To aid future analyses, therefore, we propose the term "transgender genital reconfiguration interventions" (TGRI) as a term that captures both the circumstances and immediate end of such acts — i.e., reconfiguring typically developed anatomy — and avoids some question-begging assumptions. This immediate end is distinct from genital reconstructive interventions in cases of persons with atypical genitalia due to DSD.

1. See Becket Gremmels, "Sex Reassignment Surgery and the Catholic Moral Tradition: Insight from Pope Pius XII on the Principle of Totality" Health Care Ethics USA 24.1 (2016): 6-10; Carol Bayley, "Transgender Persons and Catholic Healthcare" Ibid.: 1-5.; Kevin FitzGerald, "Viewing the Transgender Issue from the Catholic and Personalized Health Care Perspectives" Ibid. 24.2 (2016): 7-10.
2. See Charlotte Witt, The Metaphysics of Gender (New York: Oxford University Press, 2011). Note that this dyadic categorization is further complicated by the fact that the biological category of "sex" may be subdivided into one's chromosomal identity and the phenotypic expression of such, which may be affected by epigenetic factors.
3. See Albert Moraczewski, "Reflections on Chapter 10" in Sex and Gender: A Theological and Scientific Inquiry, ed. Mark F. Schwartz, Albert S. Moraczewski, and James A. Monteleone (St. Louis: Pope John Center, 1983), 301. Transgender writer Anna Magdalena notes their interconnection as well: "sex — as opposed to gender — refers to biological factors that often exist on a binary. And gender — as opposed to sex — refers to how we interpret, embody, and personalize those biological factors, as well as all peripheral issues tied to them. The fact remains that we need that second word — gender — simply because humans do in fact interpret, embody, prioritize, and personalize their sex characteristics, and whenever we're talking about sex, we're inevitably talking about gender too." "What is Gender? Or Why the Term is Both Meaningless and Indispensable https://catholictrans.wordpress.com/2015/08/16/what-is-gender-or-why-the-term-is-both-meaningless-and-indispensible/ (accessed 5/17/2016).
4. This fact is not surprising since etymologically the terms share the same original meaning.
5. American Psychological Association, "What does transgender mean?" http://www.apa.org/topics/lgbt/transgender.aspx (accessed 6/2/2016). On the linguistic change, see http://www.huffingtonpost.com/2013/06/04/gender-dysphoria-dsm-5_n_3385287.html (accessed 5/17/2016).
6. "Gender dysphoria is defined by strong, persistent feelings of identification with the opposite gender and discomfort with one's own assigned sex that results in significant distress or impairment. People with gender dysphoria desire to live as members of the opposite sex and often dress and use mannerisms associated with the other gender." https://www.psychologytoday.com/conditions/gender-dysphoria (accessed 3/7/2016).
7. Fitzgibbons et al. offer arguments to affirm the psychopathological status of the cross-identification, not merely the distress. Richard P. Fitzgibbons, Philip M Sutton, Dale O'Leary, "The Psychopathology of "Sex Reassignment" Surgery: Assessing Its Medical, Psychological, and Ethical Appropriateness" The National Catholic Bioethics Quarterly 9.1 (2009): 97-125. In contrast, TG activists have a clearly stated goal to de-psychopathologize this phenomenon, removing it from the DSM altogether. http://www.gendercentre.org.au/resources/fact-sheets/transsexualism.htm (accessed 5/3/2016). See also Alice Dreger, "Why Gender Dysphoria Should No Longer Be Considered a Medical Disorder" Pacific Standard <href="#.v9ynp0f57">https://psmag.com/why-gender-dysphoria-should-no-longer-be-considered-a-medical-disorder-f3f9211a707a#.v9ynp0f57 (accessed 6/2/2016). Explaining the linguistic change and diagnostic emphasis, the American Psychiatric Association states, "DSM-5 aims to avoid stigma and ensure clinical care for individuals who see and feel themselves to be a different gender than their assigned gender. It replaces the diagnostic name 'gender identity disorder' with 'gender dysphoria,' as well as makes other important clarifications in the criteria. It is important to note that gender nonconformity is not in itself a mental disorder. The critical element of gender dys­phoria is the presence of clinically significant distress associated with the condition." http://www.dsm5.org/documents/gender%20dysphoria%20fact%20sheet.pdf (access 6/2/2016) This linguistic and diagnositic shift is not without its critics. Cf. Lawrence, Anne A. 2014. "Gender Assignment Dysphoria in the DSM-5," Archives of Sexual Behavior. 43 (7): 1263-1266.</href="#.v9ynp0f57">
8. Alice Dreger, "Why 'Disorders of Sex Development'? (On Language and Life)" http://alicedreger.com/dsd (accessed 5/17/2016).
9. See Helen Okoye, "Gender Dysphoria DSM-5 302,85 (F64.9)" http://www.theravive.com/therapedia/Gender-Dysphoria-DSM--5-302.85-(F64.9) (accessed 5/17/ 2016); Ananya Mandal, "Diagnosis of Gender Dysphoria" http://www.news-medical.net/health/Diagnosis-of-Gender-Dysphoria.aspx (accessed 5/17/2016).
10. See Pope Francis, Amoris laetitia, ch. 8. https://w2.vatican.va/content/dam/francesco/pdf/apost_exhortations/documents/papa-francesco_esortazione-ap_20160319_amoris-laetitia_en.pdf (accessed 5/2/2016).
11. See Thomas Aquinas, Summa theologiae (ST), Ia, q. 76; Jason T. Eberl, "Aquinas on the Nature of Human Beings" Review of Metaphysics 58.2 (2004): 333-65.
12. There is some degree of debate, even among Thomists, of when a developing human body is properly formed for rational ensoulment, with Aquinas himself claiming that ensoulment occurs several weeks post-conception (ST, Ia, q. 118, a. 2). The generally, though not universally, held view, especially among Thomists operating within the Catholic tradition, is that rational ensoulment occurs at conception; see Jason T. Eberl, "Thomism and the Beginning of Personhood" in Defining the Beginning and End of Life: Readings on Personal Identity and Bioethics, ed. John P. Lizza (Baltimore: Johns Hopkins University Press, 2009), 317-38.
13. See Thomas Aquinas, Quaestio disputata de anima, a. 12 ad 7; John Finley, "The Metaphysics of Gender: A Thomistic Approach" The Thomist 79.4 (2016): 585-614; Deborah Savage, "The Nature of Woman in Relation to Man: Genesis 1 and 2 through the Lens of the Metaphysical Anthropology of Aquinas" Logos 18.1 (2015): 82.
14. See Jason T. Eberl, "The Metaphysics of Resurrection: Issues of Identity in Thomas Aquinas" Proceedings of the American Catholic Philosophical Association 74 (2000): 215-30.
15. John Grabowski,Sex and Virtue: An Introduction to Sexual Ethics (Washington, D.C.: The Catholic University of America Press, 2004), 111.
16. See Alasdair MacIntyre, Dependent Rational Animals: Why Human Beings Need the Virtues (Chicago: Open Court, 1999).
17. See ST, Ia-IIae, qq. 49ff.
18. See ST, Ia-IIae, q. 53, a. 1 ad 1.
19. With the exception of the infused theological virtues of faith and hope, which are no longer necessary (ST, Ia-IIae, q. 67).
20. See Aquinas, Summa contra Gentiles, bk. II, ch. 49; Scriptum super libros Sententiarum, bk. II, d. 19, q. 1. a. 1; In Librum de causis expositio, prop. 15. For further discussion of the importance of self-consciousness as grounding the soul's immateriality and the persistent identity of the person it composes, see John Haldane, "(I Am) Thinking" Ratio 16.2 (2003): 124-39; Lynne Rudder Baker, "The Difference that Self-Consciousness Makes" in On Human Persons, ed. Klaus Petrus (Frankfurt: Ontos Verlag, 2003), 23-39.
21. See ST, Ia, q. 89, aa. 5-6.
22. See Witt 2011, 88.
23. Megan Defranza argues that DSD does present a challenge to the binary model of sex in recent Christian anthropology. Historically, Defranza claims, the concept of the "eunuch" has existed and served the social role of containing those bodies that did not fit easily within the categories or male or female. With the recent developments in medical and surgical science, and an increasingly strongly emphasized binary, DeFranza argues that the socially useful category of the eunuch has disappeared; a development which she argues marginalizes and diminishes sensitivity toward peoples with such conditions. See her Sex Difference in Christian Theology: Male, Female, and Intersex in the Image of God (Grand Rapids: Eerdmans, 2015).
24. See Patrick Lee and Robert George, Body-Self Dualism in Contemporary Ethics and Politics (Cambridge: Cambridge University Press, 2008).
25. See Claire Ainsworth, "Sex Redefined" Nature 518 (19 Feb. 2015): 288-90.
26. See http://www.isna.org (accessed 4/30/2016); Erik Lenhart, "People Born with Intersex Conditions: Pastoral and Bioethical Considerations" The National Catholic Bioethics Quarterly 15.3 (2015): 453-63. See also Sharon Anderson, "Disorders of Sexual Differentiation: Ethical Considerations Surrounding Early Cosmetic Genital Surgery" Pediatric Nursing 41.4 (2015): 176-86.
27. https://catholictrans.wordpress.com/2015/08/18/what-is-gender-part-4-gender-as-social-grouping/ (accessed 5/18/2016).
28. It is theorized that in utero exposure to testosterone masculinizes the brain. Simon van Rysewyk provides a nice summary of this theory: "The brain is thought to develop in the male 'direction' through a surge of testosterone on nerve cells; in the female 'direction' this surge is absent .... Call this the 'standard view of gender identity'. The standard view of gender identity offers a plausible explanation of transsexualism. Since sexual differentiation of the brain occurs in the second half of pregnancy, and sexual differentiation of the sexual organs occurs in months 1-2 of pregnancy, transsexuality may occur. The relative masculinzation [sic] of the brain at birth may not reflect the relative masculinization of the genitals .... According to the standard view, transsexualism is entirely dependent on, and thereby reduces to, specific neurophysiological changes that occur during intrauterine growth in two interconnected organ types (i.e., brain and genitals)" https://simonvanrysewyk.wordpress.com/2013/04/27/mind-brain-identity-theory-brain-sex-theory-of-transsexualism-and-the-dimorphic-brain/ (accessed 6/9/2016). For a critical view of this theory, see Anne Lawrence, "A Critique of the Brain-Sex Theory of Transsexualism (2007)" http://www.annelawrence.com/brain-sex_critique.html (accessed 6/10/2016).
29. See Anna Magdalena, "A Critique of Paul McHugh's 'Surgical Sex'" https://catholictrans.wordpress.com/2014/02/09/a-critique-of-paul-mchughs-surgical-sex/ (accessed 2/29/2016); Francine Russo, "Is There Something Unique about the Transgender Brain?" Scientific American 27.1 (2016) http://www.scientificamerican.com/article/is-there-something-unique-about-the-transgender-brain/ (accessed 6/2/2016).
30. Ibid. While the language of transgender activists typically reflects this dualism, it is important to note that this could be construed as a purely materialist argument: the psychological thought (the thinking being) is one gender while the genitals (the material being) are another. However, neither arrangement is consistent with the Thomistic hylomorphic tenets of traditional Christian anthropology as affirmed magisterially by the Council of Vienne.
31. For instance, Lawrence cites "a recent article by Dhejne et al. (2011), which reported the results of a long-term follow-up study of 324 Swedish transsexual patients who underwent legal, hormonal, and surgical sex reassignment between 1973 and 2003. Despite their "successful" reassignment, these transsexual persons displayed strikingly higher mortality rates than nontranssexual controls; in particular, they were over 19 times more likely to die from suicide. They were also hospitalized for psychiatric disorders nearly 3 times more often than controls, and they attempted suicide about 5 times more often" "Gender Assignment Dysphoria in the DSM-5" http://www.annelawrence.com/gender_assignment_dysphoria.html (accessed 6/10/16); citing Dhejne, C., Lichtenstein, P., Boman, M., Johansson, A. L., Långström, N., & Landén, M., "Long-term follow-up of transsexual persons undergoing sex reassignment surgery: Cohort study in Sweden" PLoS One 6 (2011), e16885. See also Richard P. Fitzgibbons, "Transsexual Attractions and Sexual Reassignment Surgery: Risks and Potential Risks" Linacre Quarterly 82.4 (2015): 337-50; Walt Heyer, "50 Years of Sex Changes, Mental Disorders, and Too Many Suicides" The Public Discourse http://www.thepublicdiscourse.com/2016/02/16376/ (accessed 5/2/2016). In particular, Heyer cites a 2004 study of "100 international medical studies of post-operative transsexuals by the University of Birmingham's aggressive research intelligence facility (Arif)" that "found no robust scientific evidence that gender reassignment surgery is clinically effective" http://www.theguardian.com/society/2004/jul/30/health.mentalhealth (accessed 5/2/2016).
32. Dan Hitchens, "What's the truth about transsexuality?" Catholic Herald http://magazine.catholicherald.co.uk/magazine-post/whats-the-truth-about-transsexuality/pugpig_index.html (accessed 5/3/2016)_.
33. To be clear, the point of these analogues is only that someone can believe someone about the very core of their being and yet, potentially, be objectively wrong about it.
34. Our anthropological analysis clearly indicates a positive obligation to provide tailored psychological and psychoanalytic treatment as well as social support for patients in each category. These methods of non-invasive intervention are, at minimum, more clearly congruent with the exhortation found in the Catechism to come to terms with one's sexual identity as it is given by God. A Christian anthropology affirms that surgery is not required to attain the threshold for membership or acceptance in the human moral community.
35. This, for instance, is referred to as the "feminine essence" narrative in male-to-female transsexuals. See J. M. Bailey and K. Triea, "What many transgender activists don't want you to know: and why you should know it anyway" Perspectives in Biology and Medicine 50.4 (2007): 521-34.
36. Such would be an argument premised upon "brain sex" theory.

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