Do No Harm
The Catholic Bishops on Gender Dysphoria
On March 20, 2023, the United States Conference of Catholic Bishops (USCCB)—the generator of unified pastoral guidance for practicing Catholics in the United States—issued a statement on healthcare delivered by Catholic physicians and institutions. This fourteen-page document, titled the Doctrinal Note on the Moral Limits to Technological Manipulation of the Human Body (available at usccb.org/resources/Doctrinal%20Note%202023-03-20.pdf, and from which all quotations in this essay are taken), details the ethical and theological framework that forms the church’s stance on medical alterations of the human body in the pursuit of theoretical benefits.
As noted in the guidance, “modern technology . . . produces possibilities not only for helpful interventions, but also for interventions that are injurious to the true flourishing of the human person.” Recognizing that this topic sits at the cornerstone of modern medicine’s approach to the treatment of gender dysphoria and alterations to the sexual phenotype, the USCCB offers a framework that Catholic practitioners can use to serve this population in accordance with broader church teachings.
The statement begins with the foundational principle of Catholic ethics and philosophy that there is a natural order to things—an order which stems from a Creator, is by default good, and is fundamentally deserving of respect. This, the statement notes, has been described by the previous leader of the church, Pope Benedict XVI, as “an inbuilt order,” a “grammar” that “sets forth ends and criteria for its wise use, not its reckless exploitation.” Within this framework, the individual human being is made in the image and likeness of the Creator as an indivisible unit of body and soul with unequaled value.
The guidance then explores the natural progression from this foundational order to the divinely wrought “primordial duality” of the human species—male and female “in perfect equality as human persons.” The usefulness of this division has become contentious in modern society and medical practice, but as Pope Francis is quoted as affirming, “it needs to be emphasized that biological sex and the socio-cultural role of sex (gender) can be distinguished but not separated . . . and this means, in the first place, accepting it and respecting it as it was created.” Pope Francis then notes that “thinking that we enjoy absolute power over our bodies turns, often subtly, into thinking that we enjoy absolute power over creation.” The emphasis in this section of the guidance is that the created natural order is fundamentally intentional, and while we can work within and augment the natural, we should avoid supplanting it with the man-made.
Permissible & Impermissible Interventions
Transitioning out of the theoretical, the guidance clarifies the Catholic position on where and when technological intervention is permissible for the alteration of the human body. The two scenarios that are justifiable and expressly celebrated include: (1) when an intervention is aimed at repairing a defect in the body, and (2) when a part of the body must be removed for the benefit of the body as a whole. Examples would include the use of a medicine to cure a failing organ, or the removal of a gangrenous member that is poisoning the integrity of the entire system.
Thornier scenarios would include the optimization or augmentation of the appearance of an already “healthy” individual. The guidance attempts to clarify the inherent nuances of these more difficult scenarios but defers to the reality that the spirit of the law must ultimately be one’s reference point, given the vast number of circumstances that can and will arise. In the words of the USCCB, these scenarios should be approached with “correct intention and in the correct circumstances.”
In contrast, medical interventions that involve “anatomical or functional mutilation” and do not “respect the fundamental order of the body” are expressly impermissible for the Catholic practitioner. Examples of these include non-therapeutic manipulations of genetic material and next-generation theoretical “cybernetic enhancements” that may seek to replace the healthy natural body with artificial devices. The most controversial issues facing today’s physicians on this topic are the surgical and chemical techniques aimed at manipulating sexual characteristics for the purposes of simulating or delaying a sexual phenotype.
Applying the Two Criteria
So how does a practitioner reason through correct intention when treating a patient experiencing gender dysphoria and seeking alterations to his or her sexual phenotype? According to the USCCB, the necessary starting point when considering medical intervention (surgical or chemical) is application of the two criteria mentioned above. As there is no measurable clinical defect in the anatomy or function of the sexual organs or hormones of these individuals, the first category—interventions intended to return the organs to a state of health—is not applicable.
Regarding the second category—sacrificing a diseased part for the benefit of the whole—there remains a lack of evidence of an inherent sickness within the organ; it does, however, raise the question as to what constitutes a benefit to the whole of the body. The natural question that may arise when applying the second criteria is: if a person were to take his own life through suicide on the basis of this lack of surgical or hormonal intervention, is that not enough to justify a benefit to the body as a whole? (There are currently no long-term studies demonstrating a causal connection between gender dysphoria and suicide, or alternatively, a chronic reduction in suicide for people who have medically or surgically transitioned.)
The guidance does not explicitly answer this challenging question but rather approaches the dilemma from the vantage point that solutions exist or can be found that both address suffering and maintain respect for the fundamental order of the human person. In the words of the USCCB, “many people are sincerely looking for ways to respond to real problems and real suffering.” However, “an approach that does not respect the fundamental order will never truly solve the problem in view; in the end, it will only create further problems.”
For the Catholic practitioner, the contemporary push towards surgical destruction of healthy organs in favor of reconstructions and rearrangements of healthy hormonal systems is not properly ordered and is actually seen as harmful in the long run. In no uncertain terms the guidance states that “Catholic health care services must not perform interventions, whether surgical or chemical, that aim to transform the sexual characteristics of a human body into those of the opposite sex or take part in the development of such procedures.” Rather, “they must employ all appropriate resources to mitigate the suffering of those who struggle with gender incongruence . . . [and develop] solutions that truly promote the flourishing of the human person in his or her bodily integrity.”
Reemphasizing the Guiding Principles
The USCCB does not offer concrete solutions to the issue of clinically relevant gender incongruence in this document, which was not its primary intention; nevertheless, it makes clear that the “Catholic health care ministry must make every effort, using all appropriate means at [its] disposal, to provide the best medical care . . . to all patients, no matter who they may be or from what condition they may be suffering.” Speculatively, solutions could arise through a common approach among medical specialties to reinforce psychiatry’s role in these cases. And, with that, there could be a push from psychiatry to develop therapeutic options for these patients that work in concert with their bodies and anatomy, rather than attempting to alter the anatomical building blocks.
For less severe situations, it may be time to embrace a broader sensitivity and normalization within the medical domain for the spectrum of masculinity and femininity across both males and females. As is widely accepted, much of this issue lies in the world and society outside of the hospital, but within the hospitals and clinics, healthcare can be a powerful model for change in the broader society.
In summary, this doctrine, released by the USCCB, has reemphasized the guiding principles of the Catholic practitioner and delimited and ordered the ways in which medical interventions should be applied to the body. While there inevitably will be gray areas that plague the ethical arena, fundamental respect for the natural order as a gift from God must shape the Catholic practitioner’s decisions.
Thomas B. Pacheco , MD, is a resident physician at MedStar Georgetown University Hospital in Washington, D.C., specializing in psychiatry. He is a member of St. Peter’s Parish of Capitol Hill.
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