John F. Brehany, Ph.D., S.T.L.
Director of Institutional Relations
National Catholic Bioethics Center
Philadelphia
[email protected]

Becket Gremmels' recent article exploring whether sex reassignment surgery (SRS) can be justified in the Catholic moral tradition demonstrated cognizance of recent clinical and ethical literature, a cautious tone, and a helpful focus on the thought of Pope Pius XII.¹ Gremmels suggests that he made progress in showing that SRS can be morally justified in terms of at least one, and perhaps two, of Pope Pius XII's three criteria for justifiable mutilation.² However, I believe that a careful reading of the breadth and depth of Pope Pius XII's teachings³ calls into question Gremmels' method of interpretation and perception of progress. I will briefly note the two criteria upon which Gremmels bases his arguments and conclusions before outlining my arguments. My comments apply to SRS for transgender persons (individuals who choose to identify as the gender opposite their biological sex) and not on surgery for those with intersex conditions.⁴

Pius XII's first criterion for justifiable mutilation is that "the continued presence or functioning of a particular organ within the whole organism is causing serious danger or constitutes a menace to it."⁵ Gremmels correctly observes that, based on Pius XII's words and example (bilateral orchiectomy for prostate cancer), an organ, including a reproductive organ, may be justifiably removed, even if it is not diseased, so long as it contributes to a serious pathology. Based on this criterion and example, Gremmels concludes, "it appears that SRS could be justified from a Catholic moral perspective."⁶

Pius XII's third criterion is that "one must be reasonably certain that the negative effect, that is the mutilation and its consequences, will be compensated for by the positive effect . . ." Gremmels initially expresses doubts that this criterion could be satisfied given the substantial harms to the body caused by SRS (mutilation and sterilization). However, he goes on to cite another comment of Pius XII as a possible avenue for justifying SRS: "[B]y virtue of the principle of totality . . . the patient can allow individual parts to be destroyed or mutilated when and to the extent necessary for the good of his being as a whole" (emphasis added).⁷ This key phrase, Gremmels suggests, implies that considerations beyond the good of the physical body (including psychological, social, and spiritual dimensions) may be taken into account in justifying SRS. In addition, Gremmels seems to suggest that "being as a whole" could encompass the good of a person whose soul could be discordant with the identity of his or her body due to some material defect.

Again, while Gremmels' conclusions are expressed with some caution, I contend that a careful reading of the entirety of Pius XII's comments about, and careful distinctions and limitations on, applying the principle of totality militates against any use of his thought to justify SRS.

First, Pius XII required that, when applying the principle of totality, the realities at issue be precisely defined. "We respect the principle of totality in itself but, in order to be able to apply it correctly, one must always explain certain premises first. The basic premise is that of clarifying the 'quaestio facto,' the question of fact . . . The answers to these questions can never be inferred from the principle of totality itself. That would be a vicious circle. They must be drawn from other facts and other knowledge."⁸ In the case of bilateral orchiectomy, the nature of cancer as a disease and the role of the testicles in relation thereto were clearly established. The nature of the pathology of gender dysphoria and the nature of the "cure" of SRS have not been similarly established. At issue is not merely the empirical efficacy of SRS (a part of Pius XII's second criterion, which Gremmels agrees has not been satisfied by SRS to date).⁹ Rather, what arguably cannot be reconciled with the thought of Pius XII are the principled claims of transgender persons and advocates — namely, that a real disjunction can exist between a purported sexuality of the mind or soul and the clearly established sex of a healthy body, and that a cure can be provided by making the body conform to the mind. Therefore, Pius XII's first criterion cannot be satisfied by SRS for gender dysphoria in the same manner as other operations involving justifiable mutilation of the body and of reproductive organs.

Second, Pius XII's many magisterial statements on science, medicine, and health, including his criteria for justifiable mutilation and the principle of totality, are based upon the natural law. Within this framework, Pope Pius XII articulated limits on medical interventions based on respect for human nature, for the human person, and based upon the nature of the behaviors that might be performed or prescribed by way of a cure. One expression of these limits can be found in Pius XII's 1952 speech: "The patient is bound to the immanent teleology laid down by nature . . . limited by natural finality, of the faculties and powers of his human nature . . . [T]he individual must observe the hierarchy of the orders of values — or within a single order of values, the hierarchy of particular rights — insofar as the rules of morality demand."¹⁰ Pius XII gives two examples of failure to respect this hierarchy and teleology: (1) relieving psychic burdens by destroying or damaging the capacity for human freedom and (2) overcoming sexual repression through immoral sexual behavior. Both considerations are applicable to SRS for gender dysphoria. First, a "cure" for psychic distress that not only significantly mutilates a healthy human body but also attempts to remake a constitutive dimension of personal identity would not respect the immanent teleology and hierarchy of values in an embodied human person.¹¹ Second, to seek or perform "total SRS" — to enable a genotypically and phenotypically healthy male to function sexually as a female — ”is neither consistent with the thought of Pope Pius XII nor ethical, as such a person can never enter into a valid marriage.

Third, reading the entirety of Pius XII's comments undermines Gremmels' suggestion that the phrase "the good of his being as a whole" might be interpreted to justify SRS. For after these words, Pius XII specifies what he actually means — "He may do so to ensure his being's existence and to avoid or, naturally, to repair serious and lasting damage which cannot otherwise be avoided or repaired." These words, within the context of a natural law framework, argue in favor of Gremmels' initial assessment regarding Pius XII's third criterion — that substantial, destructive, and sterilizing surgery could be justified only for the sake of curing a fatal pathology, which gender dysphoria is not.¹²

There are many complex issues to explore in establishing effective and ethical responses to transgender persons. Such issues are beyond the scope of this article. What should be clear is that the teachings of Pope Pius XII on the principle of totality cannot be employed in a preemptory manner to justify SRS for transgender persons. In a climate of increasing confusion in which responses to transgender persons are being driven more by political and ideological factors¹³ than by sound Christian anthropology, theology, and science — Catholic health care providers should develop therapeutic and pastoral interventions for transgender persons which are consistent with the teachings of the Church and with the truth of the human person.

1. Pope Pius XII, Address to Delegates at the 26^th Congress of Urology, Oct. 8, 1953, in The Human Body: Papal Teachings (Boston: St. Paul Editions, 1960), at 277-81; Address to the First International Congress on the Histopathology of the Nervous System, Sept. 14, 1952, available at http://www.ncbcenter.org/resources/church-documents-bioethics/pope-pius-xii/
2. Pope Pius XII, 1953, at 277-78.
3. For a list of Pope Pius XII's allocutions on mutilation and the principle of totality, see G. Kelly, "The Morality of Mutilation: Toward a Revision of the Treatise," Theological Studies (1956): 322-23.
4. Both terminology and the nature of conditions in this area are fluid and disputed. See Benedict M. Guevin, OSB, "Sex Reassignment Surgery for Transsexuals: An Ethical Conundrum?," National Catholic Bioethics Quarterly (Winter 2014): 720-22.
5. Pope Pius XII, 1953, at 277.
6. Gremmels, at 7.
7. Pope Pius XII, 1952, at #13.
8. Pope Pius XII, 1952, at #35. This quote came at the end of a section on community interests and the authority of the state, but is applicable to the application of the principle of totality in general.
9. Gremmels, at 7. I am contrasting the issue of empirical efficacy, regarding which there is both disagreement about criteria and a paucity of evidence (Hungerford, "On the Efficacy of Sex Reassignment Procedures," 2013, accessed at https://sexnotgender.com/2013/10/16/long-term-studies-on-the-efficacy-of-sex-reassignment-procedures-objective-versus-subjective-measurements/) with the principled claims about the cause of and cure for the condition of transgender persons.
10. Pope Pius XII, 1952, #15.
11. Another statement is also pertinent here: "[I]t will never be permissible to sacrifice eternal interests to temporal goods . . . just as it will not be at all licit to disregard the latter [goods of the body and its organs] in favor of . . . the demands of the passions." Pius XII, "Address to the Italian Biological Union 'San Luca'" (1944), in National Catholic Bioethics Quarterly (Winter 2015): 727.
12. Gremmels, at 7-8.
13. See D. Soh, "The Transgender Battle Line: Childhood," Wall Street Journal, Jan. 4, 2016, accessed at http://www.wsj.com/articles/the-transgender-battle-line-childhood-1451952794

Copyright © 2016 CHA. Permission granted to CHA-member organizations and Saint Louis University to copy and distribute for educational purposes. For reprint permission, contact Betty Crosby or call (314) 253-3490.