Playing God: Changing genders? The ethics of sex reassignments

By Maria Wiering

This is the fifth part in a series.

In August, the day after he was sentenced for leaking government files, Pfc. Bradley Manning offered America a wholly different kind of revelation: He wants to become a woman named Chelsea.
“I am female,” the 25-year-old wrote in a letter to supporters. “Given the way that I feel, and have felt since childhood, I want to begin hormone therapy as soon as possible.”
A century ago, switching genders was imagined but understood as an impossible feat. Today, sex-reassignment surgery and hormone therapy, which can make a man appear to be a woman and vice versa, are gaining a national spotlight and public – and political – acceptance.
That shouldn’t be the case, says Walt Heyer, 72, who underwent sex-reassignment surgery in 1983 to live as a woman, but has returned to living as a man.
The author of several books on the topic, Heyer, who lives in North Carolina, argues against sex-reassignment surgery from his own tumultuous experience, accounts of others and data demonstrating that the surgery does little to aright underlying mental health issues.
Activists and politicians are increasingly pushing back against that view, claiming that access to sex-change operations is the next civil rights frontier.
The Catholic Church, however, finds sex-reassignment surgery problematic from the perspective of moral theology and what it means to be a human person.
Sex-change pioneering
History is peppered with examples of men acting as women, and women as men, for various reasons, but not until the 20th century could one change his or her sex organs.
Sex-reassignment surgery first gained plausibility in the American imagination in the 1950s when New Yorker Christine Jorgensen – a World War II G.I. formerly named George Jorgensen Jr. – revealed she (Associated Press style recommends use of the pronoun preferred by individuals)  had sex-reassignment surgery in Denmark. (The earliest surgeries took place in 1930s Germany.)
The Johns Hopkins Hospital in Baltimore was the first to offer sex-reassignment surgery in the United States, establishing the Johns Hopkins Gender Identity Clinic in 1966.
The medical team determined whether patients were good candidates for the surgery, and, if patients met the requirements, they would carry it out.
In its most comprehensive form, sex-reassignment surgery involves, for men hoping to live as women, the removal of testes and manipulation of the penis to construct a vagina. Breasts are constructed or enhanced through hormone therapy; cosmetic surgeries diminish Adam’s apples and create curvaceous hips.
For women who want to appear male, the process includes a full hysterectomy and skin grafts to create parts resembling male genitalia. Both surgeries render the patients sterile (which alone provides a moral objection to the surgery, according to Catholic teaching).
Attributes such as voice pitch and facial hair are regulated through lifelong hormone therapy, which may increase patients’ risk of some cancers, according to the American Cancer Society.
The language of sex-reassignment surgery and the people who opt for it can be complex. “Sex” refers to whether a person is male or female. Some argue that it can be different from a person’s “gender,” which is how a person perceives or expresses him or herself as male or female. “Transgender” describes people who believe their sex and gender are unaligned, and serves as an umbrella term for an array of ways people in this category chose to self-identify.
People who identify as transgender may or may not have undergone sex-reassignment surgeries, and may use a litany of other terms, including “transsexual,” “gender nonconforming,” “gender creative,” “gender variant” or “non-cisgender” (“cisgender” describing someone who identifies as his or her biological sex) to define themselves.
‘He’ to ‘she’?
Heyer links his questioning of gender identity to a childhood experience: his grandmother dressing him as a girl. He liked it, and eventually cross-dressed on his own. When adult family members discovered his predilection, they responded negatively, and Heyer was emotionally and sexually abused.
Heyer grew up, married, and had a rewarding career, but he continued to wrestle with identity issues, becoming an alcoholic. In the early 1980s, he decided to live as Laura Jensen.
“It was the undoing of everything,” he said.
Heyer’s wife left him, and he was briefly homeless. His substance abuse continued. While working in a psychiatric hospital, a doctor asked him if he had ever considered that he may have a dissociative disorder. He saw a therapist, and was diagnosed. It was when he began to work through his mental health issues that he realized he had been deceived, he said, and surgery never really made him a woman.
“People don’t change gender,” he said. “It’s the biggest medical fraud in the nation’s history. It’s simply a masquerade.”
Hilary Howes, 58, an event designer and Catholic who lives in Greenbelt, has had a different experience. Born male, she transitioned to living as a woman 18 years ago. Howes remembers wanting to be a girl as a child, and experimented with cross-dressing as an adult before becoming a transsexual. She does not discuss the extent to which she has altered her body to reflect her chosen identity.
“I am much more at ease, particularly in public” as a woman, Howes said. As a man, she felt people were judging her for not being “manly enough.”
A few years ago, Howes described herself as having “male genitalia and a female brain.” Now she thinks of gender as a spectrum, and her gender expression falling outside of standard “male” and “female” categories. Howes speculates that her situation may be a form of intersex, resulting from a natural genetic variance or hormonal imbalances when she was in the womb. She believes that identity shouldn’t be tied to anatomy.
Remade in Maryland
By 1979, Hopkins’ Gender Identity Clinic had operated on about 30 patients and inspired other hospitals to offer the surgery. That year, psychiatrist and psychoanalyst Dr. Jon Meyer, the clinic’s chairman, announced the findings of his study on Hopkins’ patients who had undergone the procedure. Most did not regret the surgery, but their lives were not better. Their psychosocial issues – such as family or work relationships – had not improved, calling into question the surgery’s benefits.
This contradicted the earlier findings of Dr. John Money, a distinguished medical psychologist at the Gender Identity Clinic, whose study a decade earlier of several Hopkins patients showed their lives improved after the surgery. Money was convinced that gender identity was constructed through a complex mixture of nature and nurture, but nonetheless deeply fixed in the mind. For him, if a person’s gender expression differed from the person’s anatomy, it was the anatomy – not the mind – that needed to be changed.
He tested his theories in the well-known case of David Reimer, an identical twin boy from Canada, who, after a severely botched circumcision, underwent sex-reassignment surgery and was raised as a girl under Money’s supervision. In his teens, Reimer learned the truth and resumed living as a boy, but committed suicide in 2004 at age 38.
Dr. Paul McHugh became Hopkins’ psychiatrist-in-chief in 1975, when Money’s experiment with the Reimer twins was underway. McHugh found the Gender Identity Clinic’s work suspect, and supported the end of surgeries there after Meyer’s study, seeing the work as exacerbating mental abnormalities rather than treating them. Hopkins psychiatrists have not prescribed adult sex-change operations at the hospital since 1979.
Other hospitals, however, continue to do so. One of today’s hottest debates revolves around sex reassignments for children who identify as their non-biological sex. In 2007, Boston Children’s Hospital launched the United States’ first pediatric academic program for pubescent transgender children, and other pediatric hospitals have followed suit. Convinced their children’s transgenderism is genuine, some parents and children in this situation begin working with specialists far before puberty, with the hope of blocking hormonal changes that could make living as – and surgically assuming the characteristics of – the non-biological sex more difficult later on.
Unlike the cases of Reimer and infants born with ambiguous genitalia whose parents raised them as the gender that did not conform with their genetic sex, or truly intersex children who have genetic or physical mutations, these children feel mislabeled by their healthy genitals – boys who want to be girls, and vice versa.
The church takes a more sympathetic view toward people who are physically intersexed – sometimes called hermaphrodites – who are born with ambiguous genitalia or reproductive organs. Although it was once the practice to raise babies born with this rare condition as girls, now genetics and hormones are consulted in an effort to determine biological sex. Surgical correction in this case would likely be viewed as therapeutic, not cosmetic.
The church’s concern with transgenderism goes much deeper than legal battles over public restrooms, pronouns or insurance coverage, or whether the phenomenon will be taught or affirmed in public schools. It has to do with what it means to be a human person, and the relationship between the body, mind and soul.
If it sounds philosophical, it is.
Mind vs. body
In its briefing on Gender Identity Disorder available online, the Philadelphia-based National Catholic Bioethics Center is quick to point out that sex-change operations can’t really change a person’s sex.
“A person is the unity of soul and body, and ‘soul’ should be understood not as material self, but as that which makes the body be what it is, namely, a human person,” it states. “We are either male or female persons, and nothing can change that. A person can mutilate his or her genitals, but cannot change his or her sex.”
The Catechism of the Catholic Church does not address sex-reassignment surgery directly, but Catholic ethicists often point to No. 2297, which states: “Except when performed for strictly therapeutic medical reasons, directly intended amputations, mutilations and sterilizations performed on innocent persons are against the moral law.”
The NCBC puts it this way: “We should no more respect a person’s wish to become a cyborg by cutting off his limbs and replacing them with prosthetics than respecting a person’s wish to become a different sex by cutting off and morphing his genitalia. … Psychotherapy and loving acceptance of such persons suffering from sexual identity confusion is the proper way to love them. Mutilating their bodies is not.”
Jesuit Father John J. Conley, a professor of theology and philosophy at Loyola University Maryland in Baltimore, said sex-reassignment surgery grates against the purpose of medicine and God-given male and female identities.
“The whole point of medicine is to help us heal from disease, and also to prevent disease. Being born a man, being born a woman is not a disease,” said Father Conley, who has counseled a few people with gender dysphoria, the psychiatric term for the condition in which people feel their gender and body are unaligned.
He does not doubt the sincerity with which some men and women want to switch genders, and he approaches the situation with compassion. People may experience what it means to be a man or woman outside prevailing social norms, he said, but to alter their body with hormones or surgery hurts its integrity and denies its inherent good.
As a transsexual, Howes doesn’t see sex-reassignment surgery as a mutilation, but rather a medical correction of a physical malformation – a procedure that allows a person to become his or her “authentic self.”
It’s an argument commonly made by transgender advocates: Transgenderism is a physical, not mental, condition, and it’s the body that’s in the wrong.
Some ethicists describe this view as a kind of dualism – a separation of the body and mind, with the idea that the mind is the person, and the body is merely a tool to be manipulated.
It’s a view that concerns McHugh, who retired as Johns Hopkins’ chief of psychiatry in 2001 but continues to be an active member of the department. He sat on the Presidential Council on Bioethics under President George W. Bush.
“It’s this whole idea of ‘I and this body I inhabit’ rather than ‘I and the body are one,’ ” he said. “Therefore, ‘I can do whatever I want with this body. I can intoxicate it, I can decorate it, I can cut it, I can kill it.’ This is the big fight. In my opinion, the gender dysphoria issue and transgender sexuality, this is a minor skirmish within the larger battle of ‘Can we do anything to ourselves that we want?’ ”
The church has not spoken definitively on the matter’s morality. In 2003, Catholic News Service reported that the Vatican released a document to bishops on sex-reassignment surgery’s implications for canon law. According to CNS, the document included “an analysis of the moral licitness” of sex-reassignment surgery, concluding “that the procedure could be morally acceptable in certain extreme cases if a medical probability exists that it will ‘cure’ the patient’s internal turmoil.”
Most Catholic ethicists seem to agree that therapy, not surgery, is the ethical approach to gender dysphoria. The verdict is still out in the world of psychiatry.
Psychiatry at odds
A parishioner of St. Ignatius in Baltimore, McHugh, 82, remains staunch in his position that sex-change surgeries harm the body rather than treat the mind, despite cultural and professional shifts in favor of sex-reassignment surgery.
Transgenderism results from a swath of psychosocial issues, McHugh said. When it manifests as a desire to undergo sex-reassignment surgery, he said, it’s akin to body dysmorphic disorders, such as an anorexic’s wish to starve herself skinny, or the lengths to which Michael Jackson went to alter his appearance – which is also why he thinks transgenderism is a misfit within the LGBT – Lesbian, Gay, Bisexual and Transgender – movement.
“These people (transgenders) are not driven by an erotic drive,” McHugh said. “They belong over here, amongst the people who have disorders of assumption and have an overvalued idea that their psychosocial problems will be better if they have a different nose, a different skin, a different weight or a different gender.”
He points to a 30-year Swedish study published in 2011 showing suicide rates are 19 times higher than average among those who had underwent sex-reassignment surgery. Some dismiss the findings as evidence of cultural discrimination against transgendered people, but Sweden has a reputation of being among the world’s most tolerant countries.
“We now know on quite reasonable grounds that we don’t make you better in the kinds of ways you say you’re going to be better, and there’s some clear evidence that we may be making you worse,” McHugh said.
McHugh disagrees with the position of the American Psychiatric Association, the world’s largest psychiatric organization, which “recognizes that appropriately evaluated transgender and gender-variant individuals can benefit greatly from medical and surgical gender-transition treatments.”
The APA roots its position – approved by its board of trustees last year – in “significant and long-standing medical and psychiatric literature” and advocates for public and private insurance to cover gender-transition treatments. It opposes “categorical exclusions of coverage for such medically necessary treatment when prescribed by a physician.”
The APA’s Diagnostic and Statistical Manual of Mental Orders, or DSM, last year replaced the term “gender identity disorder” with “gender dysphoria,” defined as “a marked incongruence between one’s experienced/expressed gender and assigned gender.” The switch has been interpreted by advocates and critics alike as an effort – for good or ill – to reduce the association between transgenderism and mental illness.
McHugh thinks the mainstream psychiatric community will live to regret advocating hormone replacement or sex-reassignment surgery as a viable treatment – especially for children, which he considers child abuse. Cognitive behavioral therapy would be a more appropriate course of action, he said.
Dr. Richard Fitzgibbons, a 70-year-old psychiatrist at the Institute for Marital Healing in West Conshohocken, Pa., estimates he has worked with about 100 children with gender dysphoria and their parents in the past 37 years. Research shows 80 percent of children recover from gender identity issues, which is very high, he said.
“Gender identity disorder … is fundamentally a failure to appreciate the goodness of one’s masculinity or one’s femininity,” said Fitzgibbons, a Catholic. “There’s tremendous suffering in children with gender identity disorder, and there’s great freedom in growing to appreciate the goodness and beauty of your (biological) gender, rather than mutilating a body with the belief that somehow you could feel better about yourself.”

Cultural implications
As sex-reassignment surgery gains wider acceptance, Catholics are concerned that it may be mandated in insurance coverage provided by Catholic institutions, or that Catholic hospitals and physicians will be required to offer it.
Meanwhile, Catholic leaders call for transgendered people to be treated with love and dignity, and condemn violence toward them, such as the 2011 Baltimore beating of a transgendered woman in a McDonalds that gained national attention.
It is unlikely the church would support the way transgenderism is being used to blur gender lines throughout western culture. In November, German birth certificates will allow parents to document their newborn’s gender as “X,” rather than male or female, regardless of anatomy. Australia made a similar move in July for all of its official documents. California made headlines in August for new legislation allowing transgender students to join sports teams based on their gender expression, not biology.
According to the CNS report on the Vatican document on sex-reassignment procedures’ implications for canon law, Catholics who have had the surgery are not eligible to marry, be ordained to the priesthood or enter religious life. Parishes are not to alter baptismal records to reflect a person’s “sex change.”
However, the document, a text of which is not available, reportedly affirmed the validity of marriages in which one partner later undergoes sex-reassignment surgery, because, in the church’s view, it remains a union of a man and a woman.
Few marriages survive a partner’s gender transition, but Howes’ did. The couple has a 30-year-old daughter, born when Howes, the event designer, was living as a man. Heyer, who had children before his surgery, has remarried a woman since his return to living as a man.
To be unhappy with one’s gender – and the wish to become someone other than who one is – is a consequence of the fall of man, Father Conley said.
“I think we have to be careful when we look at our desires,” he said. “There are desires within us that are very healthy, that affirm who we are, that affirm our human nature and our gifts. But there are other desires that we have – and they may be genuine, and they may be powerful – but they ultimately don’t lead to our happiness.”
Father Conley sees true happiness as more than emotional satisfaction.
“To me, happiness is fulfilling our destiny as a rational animal, and I think especially living a life of virtue – prudence, justice, temperance, having courage,” he said. “Our greatest happiness is found ultimately in the contemplation of God.”
He added: “I also think happiness is found in respecting what we’re given as part of nature.”

Catholic Review

Catholic Review

The Catholic Review is the official publication of the Archdiocese of Baltimore.