Becket Gremmels, Ph.D.
System Director, Ethics
CHRISTUS Health
Irving, Texas
[email protected]

A common argument among Catholic theologians and ethicists against sex reassignment surgery (SRS) is that it either violates the principle of totality or constitutes a direct sterilization. These procedures generally fall into one of three categories: breast (augmentation mammoplasty, subcutaneous mastectomy), genital (vaginectomy, hysterectomy, scrotoplasty, phalloplasty, penectomy, castration, vaginoplasty, etc.), and nongenital/nonbreast (liposuction, lipofilling, lowering or raising the voice pitch, chondroplasty, hair reconstruction, etc.).¹ Some of these procedures are also done outside the context of SRS for cosmetic reasons and others for therapeutic purposes.² These can certainly considered morally licit in that context.

Within the context of SRS, however, many arguments hold that procedures related to SRS are unjustified because the excised tissues and organs are healthy and the principle of totality only allows for the destruction or removal of body parts that are diseased or pathological.³ After all, the threat that the pathology poses to the health or life of the body as a whole is what justifies the violation of bodily integrity, and without a pathology there is no threat. With regard to genital procedures, without an underlying pathology, any removal or restructuring of genital organs involved in SRS would likely constitute a direct sterilization, which is always unjustified. Thus, so the argument goes, SRS is morally impermissible.

However, several authors (myself included) have noted that Pope Pius XII taught that it is not necessary for a body part to be pathological in order to justify its removal or alteration.⁴ He gives three criteria for justifying any procedure that results in anatomic or functional mutilation:

1. The retention or function of a particular organ within the whole organism is causing serious damage or constitutes a threat to it;
2. The damage or threat cannot be avoided, or even notably diminished, except by a mutilation in question and whose efficacy is well-assured; and
3. 3. It is reasonable to expect that the negative effect will be compensated for by the positive effect.⁵

Yet Pius XII recognizes that in some cases, a healthy organ's normal, natural functioning might threaten the health or life of the whole body. He says that "the decisive point here is not that the organ which is amputated or rendered incapable of functioning be itself diseased, but that its retention or functioning either directly or indirectly brings about a serious threat to the whole body."⁶ He illustrates this with the example of a bilateral orchiectomy (removal of both testicles) in a patient with prostate cancer; the testicles produce hormones that can increase the cancer's spread.⁷ Thus, according to Pius XII, the principle of totality in fact does not require a body part to be diseased or pathological to justify its amputation, removal, suppression, or destruction if its normal functioning exacerbates a pathology in another part of the body.

Furthermore, Pius XII's example shows that this is even true when the healthy body part is a reproductive organ. If it results in sterilization, this could be justified as an indirect, unintended, but foreseen side effect that is justified by the positive effect of treating, eliminating, or diminishing the pathology elsewhere in the body. Unlike a tubal ligation to prevent problems with a future pregnancy, sterility does not prevent the spread of prostate cancer but the accompanying lack of hormones does.

Given these points, it appears that SRS could be justified from a Catholic moral perspective. For the first criterion, the continued presence and normal functioning of the various body parts involved contributes to and exacerbates another illness, namely gender identity disorder, which was recently renamed gender dysphoria. For the first part of the second criterion, patients typically undergo months if not years of counseling and hormone therapy before turning to SRS as a last resort.⁸ These less-invasive interventions would have to be required in order for SRS to meet this criterion. However, it is not clear if SRS meets the last part of the second criterion or any of the third.

The second half of the second criterion relates to the efficacy of the proposed procedure. Unfortunately, it is still unclear if SRS is effective at relieving the distress of gender dysphoria. Several studies report that people who undergo SRS are largely satisfied with the results, while only about 1-3% experience serious regret.⁹ Yet, most of these studies are known to be of poor quality.¹⁰ More importantly, self-reported satisfaction does not appear to be a sufficient measure for success, especially since many of those who undergo SRS continue to have related mental health problems.¹¹ At the very least, the evidence cannot support the claim that "the efficacy of SRS is well-assured" to relieve the mental health concerns associated with gender dysphoria.

Pius XII's third criterion is a compensation of bad effects by good effects, which I read as a description of proportionate reasoning. Even if further research shows that SRS is an effective long-term treatment for gender dysphoria, it is not at all clear that SRS compensates for the negative effects of sterilization and mutilation. For example, Pius XII's example of orchiectomy in prostate cancer is an effective treatment, but the positive effect is quite significant; it extends the patient's lifespan which could allow direct treatment of the cancer to eliminate the disease altogether. With SRS, the patient's life is not at stake; the positive effect improves the quality of life but does not save or extend life. Yet, Pius XII states the principle of totality allows a patient to destroy body parts "to ensure his existence, or to avoid, and, naturally, to repair grave and lasting damage, that could not otherwise be prevented or repaired."¹² The greater the alteration, the graver the condition needed to justify it.¹³ This does not necessarily mean that every alteration must prevent or diminish a fatal illness, but one as substantial and invasive as SRS likely should. If the illness is not fatal, like gender dysphoria is not, then the condition must be grave (which gender dysphoria certainly can be), all other measures must have been tried and failed, and the intervention must be known to have high efficacy.¹⁴ As stated before, SRS does not meet this last requirement.

However, another comment from Pius XII reveals a possible avenue for morally justifying SRS. Conceptually, the principle of totality stems from the metaphysical understanding of the part-whole relationship; a part exists for the sake of the whole, thus removing the part can be justified if it benefits the whole. When applying the principle of totality to medical interventions, "whole" is typically understood to mean the patient's body.¹⁵ Yet, Pius XII states that a patient "may use individual parts, destroy them or mutilate them, when and to the extent necessary for the good of his being as a whole."¹⁶ The phrase "being as a whole" implies more than just a benefit to the physical body. It acknowledges our obligation to care for the whole person, and that health care should embrace "the physical, psychological, social, and spiritual dimensions of the human person" because Jesus sought 'physical, mental, and spiritual healing."¹⁷

If Pius XII's phrase "being as a whole" is interpreted as the whole person, it sheds new light on the principle of totality than the typical understanding that deals only with benefit to the physical body. This is especially interesting if gender dysphoria is understood as a disconnect between the soul and the body, i.e. an inability of the form to properly manifest itself due to a defect in the matter.¹⁸ That being said, much study remains to be done on the causes of gender dysphoria and the efficacy of SRS at relieving the symptoms before such a justification could occur.¹⁹

This conclusion might concern some because it does not reject SRS necessarily, as an inherently unjustified mutilation or direct sterilization, and instead rejects it conditionally, i.e., only if empirical evidence shows that the burdens outweigh the benefits.

For example, one could argue that the different intention between a woman requesting an augmentation mammoplasty for cosmetic purposes and a man requesting it as part of SRS means the two procedures necessarily have different objects. This would allow for a different moral evaluation of each one, and could justify permitting it for cosmetic purposes in women but prohibiting it for SRS in men. While this might be sufficient to avoid accusations of discrimination and cisgenderism, exploring this question is beyond the scope of this paper. However, I see this conclusion as one that recognizes the limits of human knowledge and is open to the possibility of error. Just as ethics must be based on metaphysics, so too bioethics must be based (in part) on empirically verified facts. Unfortunately, despite numerous theories regarding the origin of gender dysphoria, its cause is still unclear, and good evidence on the effectiveness of SRS (measured by something other than patient satisfaction) is lacking.

Consequently, in my judgment, procedures required for SRS that are not morally justified could be justified depending on the outcome of further research.²⁰ Ultimately, if SRS procedures are determined to be morally justified, one must still ask whether this is an appropriate use of limited resources, especially given the many demands on the health care system and the amount of capital it would require to create a center large enough to provide SRS with sufficient standards of clinical quality and safety. In the meantime, we can at least be confident that Pope Pius XII's insights on the principle of totality show that simply because SRS removes healthy, non-pathological body parts and results in sterility does not mean it is unjustified. These are morally relevant but not morally determinative factors when assessing SRS.

What do you think? If you'd like to comment on this article please email your thoughts to [email protected]. We'll collate responses for the next issue.

1. R. Ettner, S. Monstrey, and A.E. Eyler, Principles of Transgender Medicine and Surgery (Taylor & Francis, 2013), 110, 36-37.
2. For example, mastectomy and augmentation mammoplasty are regularly done for breast cancer patients, penectomy for penile cancer, phalloplasty after severe trauma to the groin, vulvoplasty after a vulvectomy for vulvar cancer, or chondroplasty for those who want to reduce the size of the Adam's apple.
3. This is an admittedly cursory summary that does not do justice to the longer arguments presented by others: Richard P Fitzgibbons, Philip M. Sutton, and Dale O'Leary, "The Psychopathology of "Sex Reassignment" Surgery," The National Catholic Bioethics Quarterly 9, no. 1 (2009): 4; Orville N. Griese, Catholic Identity in Health Care: Principles and Practice (Pope John Center, 1987), 228-29; Benedict M. Guevin, "Sex Reassignment Surgery for Transsexuals: An Ethical Conundrum?," The National Catholic Bioethics Quarterly 5, no. 4 (2005): 719, 29-34; Tad Pacholczyk, "Changing My Body to "Match" My "Identity?"," Making Sense of Bioethics (August 2015); Nicholas Tonti-Filippini, "Sex Reassignment and Catholic Schools," The National Catholic Bioethics Quarterly 12, no. 1 (2012): 93-94.
4. Father Nicanor Austriaco et al., "Medical Intervention in Cases of Maternal-Fetal Vital Conflicts," National Catholic Bioethics Quarterly 14, no. 3 (2014); Griese, Catholic Identity, 217; Emily Trancik, Cherie Sammis, and Becket Gremmels, "Prophylactic Salpingectomy to Reduce the Risk of Cancer: Ethical Considerations," Health Care Ethics USA 23, no. 1 (2015); Germain Kopaczynski, "Selected Moral Principles: Totality and Integrity," in Catholic Health Care Ethics: A Manual for Practitioners, ed. Edward James Furton, Peter J. Cataldo, and Albert S. Moraczewski (National Catholic Bioethics Center, 2009).
5. "le maintien ou le fonctionnement - d'un organe particulier dans l'ensemble de l'organisme provoque en celui-ci un dommage sérieux ou constitue une menace. Ensuite que ce dommage ne puisse être évité, ou du moins notablement diminué que par la mutilation en question et que l'efficacité de celle-ci soit bien assurée. Finalement, qu'on puisse raisonnablement escompter que l'effet négatif, c'est-à-dire la mutilation et ses conséquences, sera compensé par l'effet positif,", Pope Pius XII, "Address to the Participants of the 26^th Congress of the International Society of Urology," October 8, 1953. All English translations of Pius XII's allocutions in this article are my own, from the original French.
6. "Le point décisif ici n'est pas que l'organe amputé ou rendu incapable de fonctionner soit malade lui-même, mais que son maintien ou son fonctionnement entraîne directement ou indirectement pour tout le corps une menace sérieuse." Pope Pius XII, "Address to the Congress of Urology," 1953.
7. Pope Pius XII, "Address to the Congress of Urology," October 8, 1953. While a medical alternative is usually possible today, orchiectomy is still recommended in certain situations. Nima Sharifi, James L Gulley, and William L Dahut, "Androgen deprivation therapy for prostate cancer," JAMA 294, no. 2 (2005).
8. William Byne et al., "Report of the American Psychiatric Association task force on treatment of gender identity disorder," Archives of Sexual Behavior 41, no. 4 (2012): 765.
9. Jochen Hess et al., "Satisfaction With Male-to-Female Gender Reassignment Surgery: Results of a Retrospective Analysis," Deutsches Ärzteblatt International 111, no. 47 (2014); Byne et al., "Report of the American Psychiatric Association," 780-82.
10. Girolamo Morelli et al., "Follow-Up of Patients After Male-to-Female (Mtf) Sex Reassignment Surgery (SRS)," in Management of Gender Dysphoria, ed. Carlo Trombetta, Giovanni Liguori, and Michele Bertolotto (Springer, 2015), 185; Mohammad Hassan Murad et al., "Hormonal therapy and sex reassignment: a systematic review and meta-analysis of quality of life and psychosocial outcomes," Clinical Endocrinology 72, no. 2 (2010).
11. Cecilia Dhejne et al., "Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden," PLoS One 6, no. 2 (2011); Rikke Kildevæd Simonsen et al., "Long-term follow-up of individuals undergoing sex reassignment surgery: Psychiatric morbidity and mortality," Nordic Journal of Psychiatry (2015), Published electronically 10/19/2015.
12. "pour assurer son existence, ou pour  éviter, et, naturellement, pour réparer des dommages graves et durables, qui ne pourraient être autrement ni écartés ni réparés." Pope Pius XII, "Address to the Participants of the International Congress of Histopathology of the Nervous System," September 13, 1952.
13. See: Griese, Catholic Identity, 217-18; Albert S. Moraczewski and John B. Shea, "Genetic Medicine," in Catholic Health Care Ethics: A Manual for Practitioners, ed. Edward James Furton, Peter J. Cataldo, and Albert S. Moraczewski (National Catholic Bioethics Center, 2009), 238-39. Regarding SRS specifically, see: Tonti-Filippini, "Changing My Body," 85; Benedict Ashley, Jean Deblois, and Kevin O'Rourke, Health Care Ethics: A Catholic Theological Analysis, 5th ed. (Washington, D.C.: Georgetown University Press, 2006), 111.
14. Note that gender dysphoria is not always a grave condition as the majority of cases in children do not persist into adulthood. See Byne et al., "Report of the American Psychiatric Association," 763.
15. Thomas Aquinas, Summa theologiae, II-II, q. 65, a. 1, corpus. Griese, Catholic Identity, 218, 385-86.
16. "il peut disposer des parties individuelles pour les détruire ou les mutiler, lorsque et dans la mesure où c'est nécessaire pour le bien de l'être dans son ensemble," Pope Pius XII, "Address to the Congress of Histopathology," September 13, 1952.
17. USCCB, Ethical and Religious Directives for Catholic Health Care Services, 5^th edition, 2009, Introduction to Part Two.
18. Peter Kreeft, Everything You Ever Wanted to Know about Heaven: But Never Dreamed of Asking (Ignatius Press, 1990), 123; Griese, Catholic Identity, 229-30.
19. Even a cursory review of gender dysphoria itself and its origins are outside the scope of this article, as its focus is only on SRS and the principle of totality. Personally, I believe an amalgam of causes is at work, but I find the psychological origin theories to be particularly compelling. See Fitzgibbons, "Psychopathology." Theories of biological origin are also plausible. See Daniel Klink and Martin Den Heijer, "Genetic Aspects of Gender Identity Development and Gender Dysphoria," in Gender Dysphoria and Disorders of Sex Development, ed. Baudewijntje P.C. Kreukels, Thomas D. Steensma, and Annelou L.C. de Vries (Springer, 2014).
20. For similar positions see Griese, Catholic Identity, 230; William May, "Sex Reassignment Surgery," Ethics & Medics 13, no. 11 (1988). For those who argue that SRS is unjustified regardless of its origin, see Christopher Gross, "Karol Wojtyla on Sex Reassignment Surgery," The National Catholic Bioethics Quarterly 9, no. 4 (2009): 720; Benedict M. Guevin, "Sex Reassignment Surgery for Transsexuals: An Ethical Conundrum?," ibid.5 (2005): 732-33.

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