Rev. Kevin FitzGerald, S.J., Ph.D., Ph.D.
Dr. David Lauler Chair of Catholic Health Care
Ethics and Research Associate Professor
Department of Oncology
Georgetown University
Washington, D.C.
[email protected]

In the Winter 2016 issue of Health Care Ethics USA, two feature articles explored some of the ethical issues surrounding the medical care of transgender persons, with a particular focus on the possible surgical interventions to "reassign" a person's sexual features.¹ It is not my purpose to revisit the good work done by both authors on this topic, but to use their insights and arguments to reframe this issue in light of the 21^st century approaches to health care and medical science that I have cited before in both Health Progress and in presentations for CHA.² These frameworks — such as personalized health care, precision medicine, and systems biology — focus on integrating data and insights from a broad array of disciplines and arenas in order to obtain a more comprehensive and nuanced understanding of each patient's health situation and the most likely treatments or interventions that will preserve or enhance that patient's health.

Complexity of Sex, Gender and Human Nature
One reason for seeking a different perspective on this issue is the growing awareness of the multiple biological and social factors that potentially contribute to a person's sense of sexual and gender expression. These factors include genetic, epigenetic,³ neuroanatomical, endocrine, fetal development, and the entire array of positive and negative social experiences one can have from birth onwards. This etiological complexity of sex and gender identification is in stark contrast to the traditional manner of sex/gender identification at birth (i.e. does the baby look male or female). For the vast majority of human beings, the traditional approach has worked, so why be concerned about this issue of sex and gender identification now?

Aside from the relatively recent political and social attention being paid to transgender issues, there is good medical reason to be attentive to this area of health care. First of all, as cited in my previous article in Health Progress, the rapid progress of biomedical research will uncover surprising aspects of our human nature that run counter to our everyday concepts of health and normalcy.⁴ Apparently, from recent research into the issue of the experiences of people who identify as transgender, as well as other research in sexual behavior and identification, the complexity of human sexuality and sexual behavior may be much greater and more diverse than has been understood or appreciated. In fact, the traditional physical and behavioral differences we might easily associate with our female-male dichotomy may actually be more of a spectrum of possible combinations between the two sexes/genders than we have previously thought. This complexity is such that even experienced health care providers and researchers working with people who identify as transgender acknowledge the current lack of clarity regarding medical research, diagnoses and treatment outcomes.⁵

In one sense, these research results should not be that disruptive of our traditional concepts of male and female. Health care workers have been aware of babies born with ambiguous genitalia since the beginning of health care. The potentially disruptive part of recent research is the complexity of factors that may significantly affect a person's experience of one's sex and gender, and the complexity those interacting factors may have on experience.

Need to Update Our Understanding
In light of the research and our commitment to provide the best health care to all, we need to update our understanding of sexual characteristics and gender identification and the various ways in which both can be experienced and expressed in human beings.

This recognition of the need to update our understanding of human nature is not new within our Catholic tradition. The Catholic Church has a long history of integrating scientific advances into its understanding of Creation and human nature. In fact, advances in the understanding of human embryology that occurred in the 17^th to 19^th centuries helped inform the decision by Pius IX in 1869 to clarify the moral reasoning for acknowledging a human embryo as a human being from the time of conception.⁶ With the lack of clear scientific evidence to inform medical decision-making especially on an institutional level, and the opportunity to apply improved medical research frameworks to this issue, it may be time for Catholic health care to investigate how our understanding of human sexuality and gender might be advanced in order to better respond to the political dynamics of our time, and, more importantly, better address the needs of patients.

Research Design
One aspect of the systems approach to medical research that integrates well with Catholic health care is the need to take a broader view of the goals of the research before one undertakes designing research protocols. These goals include the patients' goods as well as the broader goods of society and humankind. Hence, it will be crucial from the outset to wrestle with issues such as the concepts of human nature that undergird the research (implicitly or explicitly), and the types of treatments or interventions that are as likely to be effective in addressing patient needs and suffering (again, implicitly or explicitly).

For instance, it can make a significant difference in how a research protocol is designed if the goal of the research is to better understand human diversity and how to help those who are not like most others to better integrate their own unique features within themselves and within society (including society integrating them well). This approach contrasts with a design focused on uncovering new data that could be used to whatever end anyone chose to use it. This could include selection of certain individuals with undesired characteristics in utero, or adding certain genetic choices to a range of options one can choose from as an autonomous agent (e.g. a parent of a child or an adult for one's self — as long as one has the resources to do so.

In other words, health care and biomedical research are different if the goal of research and treatment focuses on the physiological and social features and goods of the research participant and patient, than if the focus is a more reductionistic one of discovering the cause of, or fixing, a "problem" in the research participant or patient (physical or psychological).

This more reductionistic approach appears to be one of the problematic features associated with earlier research and treatment programs that focused on surgical interventions to solve patients' problems.⁷ These results stand in contrast to a different research approach that focused on children identified as transgender and living in supportive environments without undergoing surgical, physiologic or hormonal interventions.⁸ The results of the latter study were summarized as: "transgender children showed no elevations in depression and slightly elevated anxiety relative to population averages.

They did not differ from the control groups on depression symptoms and had only marginally higher anxiety symptoms."⁹ Though obviously limited in its scope (children aged 3-12 from supportive families) and requiring additional larger and more complex follow-up studies to investigate its broader applicability, this research succeeds in raising the issue of the appropriateness and success of intervention or treatment plans that focus on more inclusive social support and acceptance (i.e. helping the children feel good about themselves as they are) rather than surgical or technical fixes that always entail the inherent additional risks and consequences of such interventions, and that focus on the goal of making the individuals physically more like a different type of person in hopes that will make the patient feel better about themselves. This surgical or hormonal approach runs the additional risk of limiting a child's or adolescent's ability also to come to the determination that one is not transgender after all.

From the perspective of personalized health care and the goals and values of the Catholic tradition, the approach of helping a person or patient to better understand, accept and adapt to their unique health advantages and challenges would be the decidedly preferable approach. Of course, the reality for many patients is that they are already experiencing significant, or even severe, distress regarding their sense of discordance between how they see themselves and how they feel accepted within their community or society. However, even in these circumstances, one can question whether or not we have done the right kind of research and development of interventions and treatments that would work to provide the appropriate understanding and support for patients who find themselves at odds with cultural or social norms. In fact, this issue of caring for people who find that their sexual or gender experience of themselves in the bodies they have does not conform to their experience of how they seem to fit into society can be seen within a much larger cultural tension that affects the health of many people within our society.

Recent research has also indicated that many young adults — both male and female — experience an overall discontent with the shape and form of their bodies to an extent that can be detrimental to their psychological and physical health.¹⁰ Hence, the larger issue may be that all of us live in an unhealthy society that pressures many, if not most, of its people to experience themselves as incorrect, inferior or even wrong in their current physical and psychological states. While some may be fortunate enough to find understanding and supportive families and communities to grow up and live in, many do not. These less fortunate individuals can then fall prey to societal pressures about ideal body types that are not healthy and do not truly serve their good — including supposed treatments and cures that only exacerbate their suffering.

This present situation is not in line with the goals of personalized medicine or Catholic health care, and must be addressed with sensitivity, care and determination to assist those who suffer from the effects of this unhealthy aspect of our society. One place we can start is to encourage better understanding and care for any who feel ostracized or abused just for trying to live and grow into who they are, and help them resist societal pressures to harm themselves by trying to change physically, physiologically or psychologically into someone they are not.

1. Carol Bayley, "Transgendered Persons and Catholic Healthcare, Health Care Ethics USA, Winter 2016, Volume 24, Number 1, pp. 1-5; and Becket Gremmels, "Sex Reassignment Surgery and the Catholic Moral Tradition: Insight from Pope Pius XII on the Principle of Totality," Health Care Ethics USA, Winter 2016, Volume 24, Number 1, pp. 6-10.
2. Kevin FitzGerald, "The Challenges of Precision Medicine," Health Progress, Sept-Oct 2015, and "Genomic Medicine and the Family," CHA Theology and Ethics Colloquium, March 16-18, 2016, St. Louis, MO.
3. [Editor's Note: Epigenetics, in the field of genetics, is the study of cellular and physiological variations that are caused by external or environmental factors that switch genes on and off and affect how cells read genes. https://en.wikipedia.org/wiki/Epigenetics]
4. Ibid.
5. See: Dogu Aydin, et al., "Transgender Surgery in Denmark From 1994 to 2015: 20-Year Follow-Up Study," The Journal of Sexual Medicine, Volume 13, Issue 4, April 2016, pp. 720–725; and http://www.npr.org/sections/health-shots/2016/03/23/471265599/probing-the-complexities-of-transgender-mental-health.
6. DA Jones, "The human embryo in the Christian tradition: a reconsideration," Journal of Medical Ethics, 2005 31: 710-714. [Editor's Note: It also likely contributed to the Church's declaration of the Immaculate Conception as an article of faith.]
7. See footnote 5.
8. Kristina R. Olson, et al., "Mental Health of Transgender Children Who Are Supported in Their Identities," Pediatrics, Volume 137 , number 3, March 2015.
9. Ibid.
10. Stacey Tantleff-Dunn, Rachel D. Barnes, and Jessica Gokee Larose, "It's Not Just a 'Woman Thing:' The Current State of Normative Discontent," Eating Disorders 2011 October; 19(5): 392 – 402; see also http://psychcentral.com/blog/archives/2014/06/26/body-image-battles/

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.