Catholic Teaching On The Human Person and Gender Dysphoria

SUMMER 2019 FEATURE ARTICLE
chausa.org/hceusa Catholic Teaching on the Human

Person and Gender Dysphoria
Catholic Teaching on the

Human Person and Gender
Dysphoria
CATHOLIC TEACHING ON CREATION OF THE
Peter J. Cataldo, Ph.D.
HUMAN PERSON
Author’s Note: This analysis is provided in my
Catholic teaching on the creation of the human
individual capacity as an ethicist.
person as a unity of body and soul and the
place of sexual identity in this unity is the first
This analysis explores a theological and ethical
critical factor for evaluating the question of
justification for treating adults with a diagnosis
caring for and treating persons with gender
of gender dysphoria within Catholic health care
dysphoria. Catholic teaching does not make an
in light of Catholic teaching. It is based on the
absolute distinction between physical sex and
premise that Catholic teaching on the creation
sense of gender as is the case in many other-
of the human person as being either female or
than-Catholic sectors.1 Even though there is no
male independent of a person’s sense of gender
authoritative teaching on the specific question
is true. I conclude that, within certain
of providing treatment and care for persons
parameters, hormonal and surgical treatment
with gender dysphoria, the teaching on the
for adults with gender dysphoria is not contrary
nature of sexual identity within the body/soul
to Catholic teaching. I am not claiming that this
unity of the individual human person is directly
conclusion and its argument are a part of
relevant.
Catholic teaching, but only that this analysis is
consistent with Catholic teaching.
Two components of the teaching on the
creation of the human person are especially
I proceed by first giving an overview of
important for the purposes of evaluating the
Catholic teaching and its metaphysical aspects
care and treatment of persons with gender
relevant to the issue and how the teaching can
dysphoria in Catholic health care. The first is
be interpreted in light of scientific evidence
the composite unity of body and soul by which
about influences on someone’s sense of gender.
a person exists. The second is that an
This is followed by an overview of gender
individual’s act of being in the body/soul unity
dysphoria, the suffering associated with it, and
is as male or female. In Catholic teaching, God
the possibility of ameliorating this suffering
creates the individual human person as a
through treatment. I then apply Catholic
composite unity of body and soul:
teaching to treatment options and conclude by
addressing erroneous assumptions found in
The unity of soul and body is so
some moral analyses.
profound that one has to consider the
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soul to be the “form” of the body: i.e., and femininity.” This anthropology is based on
it is because of its spiritual soul that the God’s plan in the creation of man and woman
body made of matter becomes a living, which, as St. John Paul II states, “is a plan that
human body; spirit and matter, in man, ‘from the beginning’ has been indelibly
are not two natures united, but rather imprinted in the very being of the human
their union forms a single nature.2 person -men and women- and, therefore, in the
make-up, meaning and deepest workings of the
To exist at all, the human creature must be individual.”7
unified, body and soul.3 Moreover, the “living,
human body” of a person, which is made It is important to point out that while an
possible by the body/soul unity, is necessarily individual’s act of being is as male or female,
female or male. In other words, the very act by this does not entail that the soul, per se, is sexed.
which a person exists is inextricably bound up As the principle by which a human person
with the unity of body and soul and with exists, the soul by itself does not have the
existence as male or female. The Catechism of the individual materiality of a person’s sex. It is
Catholic Church affirms this: only this individual qua individuation of human
nature that is properly described as sexed (that
Man and woman have been created, is, the particular body/spirit unity that is this
which is to say, willed by God: on the person).8 Sex is not part of the definition of
one hand, in perfect equality as human human essence, but being created as male or
persons; on the other, in their female is an inseparable accident of the individual
respective beings as man and woman. existence of a person as a human substance.9
“Being man” or “being woman” is a
reality which is good and willed by God It is also important to address potential
. . . .4 difficulties regarding the teaching on the
creation of the human person as male or
Man and woman are both with one and female. For instance, is the church’s teaching
the same dignity “in the image of God.” on the role of sexual identity in the creation of
In their “being-man” and “being- the human person question-begging insofar as
woman,” they reflect the Creator’s it assumes that sexual identity is determined by,
wisdom and goodness.5 or is reducible to, one’s physical sex
characteristics at birth? But what if it is not
The Catechism also calls attention to Genesis sufficient to determine sexual identity in this
5:1-2: “When God created man, he made him way? Scientific evidence indicates that a
in the likeness of God. Male and female he person’s sense of gender could be influenced by
created them, and he blessed them and named multiple biological and social factors. Such
them Man when they were created.”6 Thus, to factors include genetic, epigenetic,
come into being as this or that particular neuroanatomical and endocrine causes, fetal
human individual created by God, is to come to development, and both positive and negative
be as female or male according to Catholic social experiences.10 Pope Francis recognizes
teaching. St. John Paul II wrote about an that “masculinity and femininity are not rigid
“anthropological foundation for masculinity categories.” However, he also states that it “is
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true that we cannot separate the masculine and

the feminine from God’s work of creation, The biological, psychological, or
which is prior to all our decisions and
experiences,” including those experiences that social factors that contribute to
he characterizes as “understandable a person’s sense of gender
difficulties,” “human weakness,” and the
“complexities of life.”11 In other words, such should not be conflated with
factors do not have a bearing on God’s creative the ontological reality of God’s
act of the existence of an individual human
person, or on our understanding of the act in creative act.
its ontological dimension as it is described in
Catholic teaching. Similarly, the fact that
biologically we might not know the sex of evidence does not mean that the human being
persons with intersex conditions or disorders of has no ontological dimension by which we can
sex development, such as Androgen also know the individual. The Congregation for
Insensitivity Syndrome (AIS), does not preclude Catholic Education, in its “Male and Female He
the fact that God creates these individuals as Created Them” Towards A Path of Dialogue on the
male or female ontologically considered.12 Question of Gender Theory in Education, draws on
the work of St. John Paul II, and makes a
The biological, psychological, or social factors distinction that is helpful here. The fact that the
that contribute to a person’s sense of gender method of biology is different than the method
should not be conflated with the ontological of metaphysics does not mean that the order of
reality of God’s creative act. That God creates nature is reducible to the order of biology.
the individual human person as either male or Rather, the order of nature, through empirical
female qua ontological reality is not and metaphysical methods, may be understood
incompatible with that same individual having a as encompassing both the “order of biology”
different sense of gender qua biological, and the “order of existence” comprehended in
psychological, or social factors nor with the fact its ontological dimension and its relationship to
that perhaps only five to ten percent of people God the Creator.14
fall between the two typical phenotypic
boundaries of male and female. As a variation To hold that God creates each individual
on what Elliott Bedford and Jason Eberl have person and also to make the unqualified claim
explained in a recent article, creation of the that there is no female/male dichotomy but
human individual is per se as female or male, but only a spectrum of possible combinations of
this does not necessarily preclude or prevent physical sex characteristics and gender
the per accidens reality that the created individual awareness is to assume that God’s creative act
perceives her or his gender as being the of the human individual can be determined by
opposite of the physical sex characteristics biological, psychological, and social factors
possessed at birth, or that an individual may post-creation. It is to assume that the creation
have an intersex condition.13 The fact that there of the human individual is reducible to reality in
is sexual and gender variation among individual its particular biological, psychological, and
human beings known through empirical social dimensions and is a reality absent of an
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ontological dimension.15 However, to determine

the sex of an individual by that person’s sense Thus, the teaching on the creation of the
of gender post-coming-into-being along a human person as male or female qua
spectrum denies the principle of individuation ontological reality is not informed or advanced
at the point of creation. Though God sustains a by any scientific evidence about the complexity
person’s act of existence, this act, once in act, of biological, psychological, and social factors
does not itself evolve or develop into some that might influence an individual person’s
other act of existence, and, therefore, neither sense of gender. Rather, what this evidence
does the individual’s created existence as female or informs is the ethical evaluation of the
male. circumstances associated with gender dysphoria
and specific options available for alleviating the
The independence of God’s action qua suffering of gender dysphoria consistent with
ontological reality from particular results qua the teaching on God’s creative act as an
biological, psychological, or social reality in any ontological reality. This is the approach that I
given case is similarly exhibited in how the will use in the analysis below regarding the
dignity of the anencephalic child may be viewed moral status of treatment options within
in the Catholic moral tradition. The condition Catholic health care. Given these points
of anencephaly does not prevent God’s creative regarding the empirical evidence about physical
act of the fetus, who develops anencephaly sex characteristics, the personal sense of gender
accidentally, from being fully human in essence on the one hand, and God’s creative act of a
and existence.16 Anencephaly is a congenital person on the other, it is not contradictory to
abnormality, which is determined post-creation claim that a person’s sense of gender can be
by biological causes. Yet, this anomaly does not contrary to the ontological dimension of the
interfere with or alter the ontological dimension creation of that person as male or female.
of God’s creative act of this individual as fully
human. The creation of the individual human Another potential objection might be that the
person as a substance, with a spiritual soul, and act of existence of a person as a body/soul
as an animal who is male or female, delimits the unity should not be determinative of what is
kind of being according to which God creates. essential to who the person is, but rather that
However, precisely as an individual human, the human person is relational. The earlier work
each person always has the potency for of Pope Emeritus Benedict XVI might be cited
variation relative to other individual persons. to make the objection. In a 1990 article on the
notion of person in theology, then Cardinal
The difference between the formal principles Ratzinger argued that “relativity toward the
by which an individual comes to be as a certain other is the human person. The human person
kind of being and the material principle by is the event or being of relativity” (emphasis
which an individual exhibits particular added).17 Using this view, it might be objected
differences with individuals of the same kind that the body/soul unity of a person is
means that the ontological dimension of an secondary to defining the human being as
individual’s existence and the specificity of the relational, and as such, sexual identity ought not
person’s individuality are not mutually to be inextricably tied to the individuation of
exclusive. the body/soul unity of the person. Rather, since
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the human being is defined as relationality to new life. All of these points are evident in the
others, sexual identity ought to be determined following texts from the Catechism, beginning
as a relational reality. It is not defined by with Genesis, 1:27:
stagnant ontological strictures, but rather is
defined over time as persons relate to others ‘God created man in his own image . . .
and to their environment. male and female he created them’; He
blessed them and said, ‘Be fruitful and
In response, it could be argued that in Catholic multiply.’19
teaching the soul-as-form and the body-as-
matter are principles of being that at the The Catechism elaborates on this biblical
moment of creation unify in an individual’s act teaching in many places, including #2332.
of existence as either female or male. In his
article, Cardinal Ratzinger prescinds or excludes Sexuality affects all aspects of the
from consideration the questions of the human person in the unity of his body
soul/body unity and individuation. He does not and soul. It especially concerns
reject the reality of the human person as a affectivity, the capacity to love and to
substance constituted by a body/soul unity, but procreate, and in a more general way
only that the category of substance defines the aptitude for forming bonds of
human essence. Insofar as relationality defines communion with others.20
the essence of human nature for Cardinal
Ratzinger, he does not deny the reality of the The ontological relation between the creation
individuation of the human person as male or of the human person as female or male and the
female, which is a reality entirely compatible complementarity of the sexes is also
with the human person as relational. It could be underscored by St. John Paul II: “When the
argued that to be “relativity toward the other” Book of Genesis speaks of ‘help’ [for Adam], it
is not possible without at the same time being a is not referring merely to acting, but also
body/soul unity as male or female. to being. Womanhood and manhood are
complementary not only from the physical and
It is just such an ontological basis of the person psychological points of view, but also from
as relational that describes another aspect of the ontological. It is only through the duality of
Catholic teaching on the creation of the human the ‘masculine’ and the ‘feminine’ that the
person. This is evident in the statement from ‘human’ finds full realization.”21 These texts on
the Catechism that “God created man and the creation of the human person indicate that
woman together and willed each for the other.”18 in Catholic teaching being male or female is
Notice that intrinsic to the creation of integral to the creation and act of existence of
individual men and women according to this an individual person and is a fundamental
text is an ordering or tendency toward others of source of relating to and being in communion
the opposite sex. This reinforces the reality that with others. The texts also show that the
the individual human person is created as ordination toward the generation of new life
female or male, is created in relation to others, within the complementarity of the sexes is
and has an intrinsic ordination toward others of integral to the sexual identity of the person as
the opposite sex that entails the generation of male or female. The intrinsic relationship
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between being-female and being-male, the essential differentiating capacity being the
complementarity of the sexes, and the reproductive capacity. As the teaching from the
relationality of human persons is emphasized in Catechism indicates, “being-man” and “being-
Male and Female He Created Them: Towards A Path woman” delimits ways or kinds of being, and
of Dialogue on the Question of Gender Theory in what makes the specific difference to these
Education: “The self is completed by the one particular kinds of being are the primary sex
who is other than the self, according to the specific characteristics. The contingency of individual
identity of each person, and both have a point material existence means that there will be
of encounter forming a dynamic of reciprocity variation among the primary sex characteristics
which is derived from and sustained by the of individual females and males, but this does
Creator.”22 not contradict the fact that being-female and
being-male in God’s creative act of the
PRIMARY AND SECONDARY SEX individual (at the moment of creation) is
CHARACTERISTICS: A PIVOTAL defined generally by characteristics that
DISTINCTION differentiate these ways of being. Thus, even
though biologically there may be slight or great
The procreative ordination toward the variation among the primary sex characteristics
generation of new life as an intrinsic element of of individuals, these characteristics are still
the creation of individual humans as female or ontologically integral to God’s creative act of
male forms the basis for understanding the individual persons as female and male, not in
distinction between primary and secondary sex their potency for difference among individuals
characteristics as representing what is and is not but in the way they delimit the kind of being
ontologically integral to the creation of the into which an individual is created. Thus, the
individual human person as female or male. claim of their integral status is not disproved,
Primary sex characteristics are chromosomes for example, simply because individuals can
and phenotypic features that are directly related have the atypical conditions of intersex, or
to reproduction and are indicative of biological because the primary sex characteristics can be
sex. Secondary sex characteristics are removed, or because a person may be sterile by
phenotypic features not directly related to accident of nature.24
reproduction.23 The primary sex characteristics,
the reproductive organs in particular, are It is important to understand that delineating
integral to the ordination to new life intrinsic to the ontological significance of the primary and
the creation of an individual as female or male. secondary sex characteristics for the creation of
They are ontologically “integral” because the human person as female or male, and
together they constitute the material condition identifying the primary sex characteristics as
by which ontologically an individual is created ontologically integral to God’s creative act, does
as female or male, even though biologically not reduce human sexuality to the reproductive
there is variation in these characteristics among organs and is consistent with the totality of
individuals. sexuality as being inclusive of its biological,
spiritual, emotional, and psychological
Ontologically, to be male or to be female is to dimensions. Human sexuality is a complex
be constituted by certain capacities, the reality and different aspects of it can be ordered
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differently to different objects but retain their secondary sex characteristics in order to treat
unity in the real person. Just as the conjugal act gender dysphoria may be morally permitted in
is integral to the complete and reciprocal gift of Catholic health care, particularly because the
spouses to each other does not mean that their secondary sex characteristics do not have an
relationship is reducible to the conjugal act, so integral ontological status. The integral status of
too identifying the primary sex characteristics as the primary sex characteristics, however, means
integral to God’s creative act does not reduce that modifying them for the sole purpose of
human sexuality to organs. treating gender dysphoria would not be morally
permitted.26 Before this making this case and
It is also important to understand that the applying the ontological distinction between the
ontological significance of the difference primary and secondary sex characteristics to the
between the primary and secondary sex question, a brief overview is needed of what
characteristics does not divide the human gender dysphoria is, the suffering that it
person or entail a dualistic view of the person. presents, and the prospects for treatment.
Insofar as this distinction is based on a real
biological difference among the sex GENDER DYSPHORIA AND ITS SUFFERING
characteristics within one and the same person
it cannot be interpreted as being contrary to the The Diagnostic and Statistical Manual of Mental
unity of the person. Similarly, it is not a Disorders (DSM–5) defines the diagnosis of
dualistic view to hold that not all aspects and gender dysphoria in adolescents and adults in
characteristics of the human person function the following way:
equally with respect to the individual’s
existence. The fact that there is a real A. A marked incongruence between one’s
distinction between body and soul, or a experienced/expressed gender and
distinction among the powers of the soul itself, assigned gender, of at least 6 months
does not mean that the individual human being duration, as manifested by at least two
does not exist as a unified whole. For the same of the following:
reason, the fact that ontologically a person is
created as female or male and that this is 1. A marked incongruence
contrary to the individual’s sense of gender between one’s
identity does not entail a dualistic view of the experienced/expressed gender
human person.25 and primary and/or secondary
sex characteristics (or in young
I will argue below that the ontological adolescents, the anticipated
significance of the distinction between the secondary sex characteristics).
primary and secondary sex characteristics 2. A strong desire to be rid of
means that there is a corresponding significant one’s primary and/or secondary
moral difference between directly affecting the sex characteristics because of a
primary sex characteristics and directly affecting marked incongruence with one’s
the secondary sex characteristics for the experienced/expressed gender
purpose of treating gender dysphoria. Under (or in young adolescents, a
certain conditions, directly affecting the desire to prevent the
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development of the anticipated colleagues “found that trans people attending

secondary sex characteristics). transgender health-care services present with a
3. A strong desire for the primary high prevalence of psychiatric disorders and
and/or secondary sex psychopathology.”30 This suggests the need for
characteristics of the other better access to psychiatric and psychological
gender. care for many individuals. Indeed, a number of
4. A strong desire to be of the studies have suggested that gender dysphoria is
other gender (or some an independent risk factor for suicidality and
alternative gender different that lifetime suicide attempts may be as high as
from one’s assigned gender). 46% among trans men 42% among trans
5. A strong desire to be treated as women.31 A study by Gunter Heylens and his
the other gender (or some colleagues found that the rate of affective and
alternative gender different anxiety disorders was higher among persons
from one’s assigned gender). with gender dysphoria than the general
6. A strong conviction that one population. The study observed that “the
has the typical feelings and incongruence between gender identity and
reactions of the other gender social life and/or bodily characteristics
(or some alternative gender experienced by individuals diagnosed with
different from one’s assigned gender identity disorder can cause much
gender). distress that may lead to affective and anxiety
problems and even disorders.”32 The suffering
B. The condition is associated with of transgender persons can also be caused by
clinically significant distress or social stigma. One recent study by Walter
impairment in social, occupational, or Bockting and his colleagues showed “in
other important areas of functioning.27 comparison with norms for nontransgender
men and women, our transgender sample had
A recent review by Ellen Marshall and her disproportionately high rates of depression,
colleagues of 31 studies in the scientific anxiety, somatization, and overall psychological
literature on the rates of non-suicidal self-injury distress.”33
and suicide among transgender persons “found
a strong association between gender dysphoria, Studies also show that psychopathology and
non-suicidal self-injury (NSSI) and suicidality psychiatric disorders associated with gender
(suicidal thoughts, suicide attempts and suicide dysphoria are amenable to improvement with
rates).”28 The review also reports that “studies treatment.34 With respect to hormone therapy, a
investigating prevalence rates of suicidality recent systematic review concluded that “when
among trans people showed an increase of treated with hormone therapy, gender
suicide ideation, suicide attempts and suicide dysphoria individuals reported less anxiety,
rates, even after transition and sex reassignment dissociation, perceived stress, social distress,
surgery when compared to the cisgender and higher mental health-related quality of life
population [ people whose gender identity and self-esteem.”35 With respect to surgery for
matches their biological sex].”29 In another gender dysphoria, it is recognized that we “need
literature review, Cecelia Dhejne and her more studies with appropriate controls that
8
examine long-term quality of life, psychosocial …we “need more studies with
outcomes, and psychiatric outcomes to appropriate controls that
determine the long-term benefits of surgical
treatment.”36 At the same time, a recent study examine long-term quality of
has found that “generally SRS [Sex life, psychosocial outcomes, and
Reassignment Surgery] may reduce
psychological morbidity for some individuals psychiatric outcomes to
while increasing it for others.”37 The Sweden determine long-term benefits of
cohort study concluded that “surgery and
hormonal therapy alleviates gender dysphoria” surgical treatment.”
but that these therapies are “apparently not
sufficient to remedy the high rates of morbidity
and mortality found among transsexual relevance of the primary/secondary sex
persons.” The study authors concluded that it is characteristics distinction for understanding
“important to note that the current study is what is ontologically integral and what is not
only informative with respect to transsexuals integral for the creation of the individual
[sic] persons’ health after sex reassignment; no person as female or male, certain interventions
inferences can be drawn as to the effectiveness as direct treatment specifically for gender
of sex reassignment as a treatment for dysphoria in adults can be ethically justified.
transsexualism. In other words, the results Interventions for the treatment of gender
should not be interpreted in such a way as to dysphoria can be justified by the principle of
suggest that sex reassignment per se increases totality, if, and only if, the services are restricted
morbidity and mortality.”38 The World to secondary sex characteristics. Pope Pius XII
Professional Association for Transgender expressed the principle in this way: “It declares
Health makes the general observation that that the part exists for the whole, and that,
“while many transsexual, transgender, and consequently, the good of the part remains
gender nonconforming individuals find comfort subordinated to the good of the whole: that the
with their gender identity, role, and expression whole is that which determines the part and can
without surgery, for many others surgery is dispose of it in its own interest.”40 Consistent
essential and medically necessary to alleviate with the principle of totality, the loss or
their gender dysphoria. . . . Follow-up studies alteration of secondary sex characteristics
have shown an undeniable beneficial effect of through hormonal or surgical treatment may be
sex reassignment surgery on postoperative justified for the good of the whole person for
outcomes such as subjective well-being, the following reasons: (1) the presence of
cosmesis, and sexual function.”39 secondary sex characteristics may, in a given
case, represent a serious harm to the well-being
INTERVENTIONS INVOLVING SECONDARY of the patient; (2) the intervention can be
SEX CHARACTERISTICS AND THE effective for the patient; and (3) the good of
PRINCIPLE OF TOTALITY restoring well-being and avoiding grave harm is
proportionate to the loss.41
Given Catholic teaching on the creation of the
human individual examined here, and the
9
Evidence for the first two conditions has been to justify treatment of gender dysphoria.45 His
indicated. Proportionality is also key to this review focuses on Catholic teaching and
argument. Interventions on secondary sex theological opinion from the 1940s to the
characteristics directed to the good of the present. In my view, there are three flaws in
whole of the person are proportionate means to Jones’ analysis of these historical sources. These
remedy the lack of psychological and emotional flaws are based on misconstruing the
cohesiveness and even suicidality. They are also distinction between historical interpretation of
proportionate since the sex characteristics the principle and the intelligibility of the
affected do not have an integral role for the principle itself.
body/soul unity of the individual human
person as female or male. These interventions The first flaw in the historical interpretation of
can be accomplished without being directed the principle is that the focus and object of the
toward eliminating primary sex characteristics principle is reducible to the physical integrity of
that are integral to who the person is as a the person, such that the intelligibility of the
created being.42 principle is identified with the preservation of
the physical whole of the person. This does not
Similarly, the use of hormonal therapy, even mean that Catholic theologians have historically
though it can have a sterilizing effect in the rejected the notion that the human person is a
long term, is permissible for the purpose of body/soul unity, or that they rejected the fact
treating gender dysphoria. Any sterilizing effect that people may experience psychological
on the primary sex characteristics would be conditions that are in some way related to the
foreseen but unintended.43 Moreover, the sex body; but what some have assumed is that the
hormones affected in hormonal therapy for object of the principle of totality qua moral
gender dysphoria considered in themselves are guide for evaluating actions that directly cause
neither primary nor secondary sex harm to the body is delimited to physical parts
characteristics. They are causes of primary and and the physical integrity of the person. For
secondary sex characteristics, but as causes, and Jones and his most of his sources, the part-
because they are found in both males and whole relationship specified by the principle is
females (their different levels in each sex conceptualized strictly as a relationship of
notwithstanding), they do not qualify as sex organic part to physical whole.46 In this
characteristics per se.44 For these reasons, understanding of the principle, integrity is
hormonal treatment for gender dysphoria is not reduced to physical integrity that can be
deliberately directed at eliminating a primary justifiably preserved through the sacrifice of
sex characteristic that is integral to the creation physical parts. Thus, the only ethically
of the person as female or male. justifiable physical interventions to treat
psychological conditions on this view are
A RESPONSE TO THE VIEW THAT TOTALITY treatments for conditions that have a basis in
CANNOT BE APPLIED organic disease.
A recent article by David Albert Jones reviews However, since the whole of the human person
the history of Catholic teaching and theological is constituted by the composite unity of body
opinion on the principle of totality and its use and soul, aspects of a person that are
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immaterial qualify as parts of the whole just as that gravely affect a person’s freedom to the
the physical aspects qualify. Thus, to modify extent of turning the person into “an
organic parts to preserve the psychological well- automaton.”50 Thus, Pius’ limits on the
being of a person, whether those physical parts application of the principle of totality were not
are diseased or not, is not contrary to the generated from a view of the principle that
principle. Pope Pius XII described and applied reduced the notions of integrity and part-whole
the principle of totality with an understanding relations to the physical dimension of the
of human integrity as encompassing both person. The fact that the principle was applied
physical and psychic integrity. Even when he to the relationship of the individual to the state
referenced the “destruction or . . . mutilation of also indicates that the notions of a whole and
anatomic or functional character,” he did not relation of part to whole as they function in the
reduce the meaning and application of the principle are not reducible to physical reality.51
principle to physical integrity.47 His text bears
this out: Consistent with this view of Pius’ application of
the principle of totality is the fact that he used
. . . he [the patient] does not possess the term “organism” in three different senses,
unlimited power to allow acts of only one of which is limited to the physical. For
destruction or of mutilation of Pius, “organism” can apply to the physical
anatomic or functional character. But, organs and their integrated physical function, to
in virtue of the principle of totality, of the organism of the whole person as unity of
his right to employ the services of the body and soul, and to the “moral organism” of
organism as a whole, he can give humanity. Pius used the term “organism” to
individual parts to destruction or mean an integrated whole of parts, whether that
mutilation when and to the extent that whole is material, immaterial, or a composite of
it is necessary for the good of his being the two. Here is a sampling of how he used
as a whole, to assure its existence or to these terms:
avoid, and naturally to repair, grave and
lasting damage which could otherwise The physical organism of the “the man”
be neither avoided nor repaired.48 is one complete whole in its being. The
members are parts united and bound
The concepts of “services of the organism as a together in their very physical essence.
whole” and “being as a whole” are related but They are so absorbed by the whole that
distinct as they function in this text. Because they possess no independence. They
Pius does not restrict the meaning of “being as exist only for the sake of the total
a whole” to physical integrity, his use of organism and have no other end than
“services of the organism of the whole” that of the total organism.
legitimately includes modification on organic
parts for the good of the whole of the It is entirely a different matter in the
individual understood as a unified physical and case of the moral organism that is
psychic composite.49 Pius’ prohibition against humanity. This constitutes a whole only
mutilation of the body that follows his text in regard to act and finality.52
quoted here is limited to medical experiments
11
In an address to country doctors, Pius uses the organism,” and “body” includes the immaterial
term “whole organism” to describe the human dimension of the human person, his
person as a composite unity of body and soul: understanding and application of the principle
of totality ought not to be interpreted
You [the doctor] are in a position to exclusively in terms of material integrity or
consider man in his own nature of body physical part-whole relations of the human
and soul subject to reciprocal influence, person.56 There may be reasons why medical
coexisting in the human composite. intervention is not justified for gender
According to nature, body and soul are dysphoria, such as when the intervention
not in opposition, but in intimate and directly violates some essential aspect of human
constant collaboration. And so when, as nature or a person’s existence, but a reason
often happens, you can be of aid to based on a physicalist interpretation of totality
souls, you must act with the conviction is not one of them.
that thus you render a sound service to
the whole man, not only to his spiritual A second flaw in Jones’ analysis is that the
part, for often this will contribute to the ontological meaning of the distinction between
greater efficiency of the whole the primary and secondary sex characteristics is
organism.53 not recognized. Partly because the
interpretation of the principle considered by
Similarly, Pius describes the “physical Jones did not take into account the ontological
organism” of the person as a “subsisting unity,” significance of the sex characteristic distinction,
which is the substantial unity of body and soul: it focused on treatment that affects the
“What follows with regard to the physical reproductive organs. As a result, use of the
organism? The master, the person who uses principle of totality to justify treatment for
this organism, which possesses a subsisting gender dysphoria has historically been rejected.
unity, can dispose directly and immediately of Even Jones’ recognition of the possible ethical
the integrant parts, the members and organs, justification of “minor medical procedures” for
within the framework of their natural finality.”54 gender dysphoria that do not destroy
For Pius, the “physical organism” of the human “biological function” is not grounded in an
individual is not intelligible apart from the ontological distinction. 57 However, recognition
subsisting unity of the individual. In an address of this distinction makes a critical difference to
to the Italian Medical-Biological Union of St. the proportionality of goods and evils weighed
Luke, Pius pointed out that while the work of by the principle, as has been shown.
physicians directly affects “the body with its
members and organs, [this work] will The third flaw, related to the first, is that the
nevertheless concern too the soul and its historical interpretation does not take account
faculties” due to the “compenetration of matter of the fact that the psycho-social effects of a
by spirit in the perfect unity of the human dysphoric condition may be legitimately
composite.”55 considered in an application of the principle.
Since application of the principle is not
Insofar as Pius’ use of the terms “organism,” reducible to physical totality, its use to evaluate
“physical organism,” “whole organism,” “total the moral status of treating gender dysphoria is
12
…psycho-social
suffering is a legitimate whole of the person as a body/soul unity. The
part of the whole suffering of gender dysphoria is as much a
individual who has legitimate part of the whole person as is any
other type of suffering, just as virtue and vice
gender dysphoria, and is and human behavior itself also constitute parts
a part that threatens the in the part/whole relation of the person. In the
case of interventions on the secondary sex
health of the whole characteristics, they have an intrinsic relation to
person. the suffering of gender dysphoria precisely
because they are sex characteristics; therefore,
the removal or altering of these characteristics
represents, consistent with the principle of
not restricted to whether or not the origins of totality, the sacrificing of one part to heal
the condition reside in organic disease. Rather, another part for the sake of the whole in such a
psycho-social suffering is a legitimate part of way that does not violate the individual’s
the whole individual who has gender dysphoria, created existence as female or male.
and is a part that threatens the health of the
whole person. Therefore, this suffering is a INTERVENTIONS INVOLVING PRIMARY SEX
legitimate factor in the application of the CHARACTERISTICS
principle to determine whether a physical part
may be sacrificed or altered to heal the part that Due to the integral nature of the primary sex
is threatening the whole. characteristics with respect to sexual identity as
a component of the body/soul unity of the
Jones explicitly argues that the distress of individual human person, interventions directed
gender dysphoria is an “intentional object of a specifically toward and only for the purpose of
mental state” and as such cannot be in a “part- removing such an integral sex characteristic are
to-whole relation” that could be evaluated by not justified by the principle of totality. The
the principle of totality.58 The distress is about a reason is that the sole immediate end (moral
physical aspect of the person, it is not the object) in this case is the removal of an integral
physical object itself. He concludes that as a sex characteristic, precisely and insofar as it is a
result of this fact the principle of totality cannot primary sex characteristic. While it is true that
be used to justify what he calls “serious and its presence is a cause of severe psychological
lasting harm at the level of function,” which he pain, this pain is inextricable from the fact that
does not define.59 The assumption behind this it is a reproductive organ of a certain sex (a
claim is that only physical objects have the primary sex characteristic); as such, its removal
nature necessary to be parts of the whole that is cannot be justified by the principle of totality
the person as considered in the principle of because it is essential to the whole of the
totality. However, this is the very thing in person as male or female. In contrast, in the
question. The fact that the distress of gender case of sacrificing a reproductive organ that is a
dysphoria is about a physical object and is not pathophysiological threat to the whole
the physical object itself does not disqualify the organism (whether or not the reproductive
reality of the distress as a legitimate part of the organ itself is functioning normally), the moral
13
object of the act is the cessation of the threat or orchiectomies directly to treat
precisely insofar as there is either a disease pathophysiological conditions of the uterus or
involving the organ, or a known threat being testes but which happen to coincide with their
caused by a healthy organ, not precisely and desire for gender transition.
specifically the removal of the organ as an
integral sex characteristic.60 An example of this Foreseeing the intent of the patient does not of
distinction is the provision of a hysterectomy itself mean that the Catholic institution shares
solely and only to treat gender dysphoria and a that intention or approves gender transition.
hysterectomy to treat a pathophysiological Foreseeing and intending are not mutually
condition of the uterus, whether or not the inclusive. Though foreseeing and intending can
patient has gender dysphoria. While the be related in specific actions, they arise from
ontological individuation of the individual different powers of the soul—foreseeing from
person as female or male cannot be changed by the intellect, and intending from the will.
removing sex characteristics that are integral to Moreover, if merely foreseeing the consequence
an individual’s unity, to remove them strictly of an action entailed the intention of it, then the
for the purpose of treating gender dysphoria is traditional principle of the double effect would
directly to prevent the functionality of this not be possible. When we treat a
integral component precisely as it represents pathophysiological condition that affects
the individuation of the person as male or primary sex characteristics, we intend treatment
female. For a Catholic health care institution to of the condition. Foreseeing that the
approve such procedures would be to share in institution’s actions will coincide with the
the same object of eliminating a sex patient’s intention for gender transition in both
characteristic integral to the creation of the cases does not undermine the moral legitimacy
person for its own sake. of the interventions.
CONVERGING INTENTIONS St. Thomas Aquinas addresses this problem

when he raises the possibility that one physical
What if clinical indications, e.g., a reproductive act may represent more than one moral act:
organ with a pathophysiological condition,
coincide with the patient’s desire for gender It is possible, however, that an act
transition? May we treat this patient for the which is one in respect of its natural
pathology, knowing that it will indirectly assist species, be ordained to several ends of
gender transition? While the alignment of the the will: thus this act “to kill a man,”
intervention with the subjective intention of the which is but one act in respect of its
patient for gender transition is foreseen by the natural species, can be ordained, as to
institution, the moral object (immediate end), an end, to the safeguarding of justice,
intention, and relevant circumstances of the and to the satisfying of anger . . . .61
institution’s actions are defined by, and can be
properly characterized as, the direct treatment The fact that there is one exterior act that the
of a present pathophysiological condition or patient may intend for gender transition, which
risk of one. Examples of this distinction are intention a Catholic health care institution
transgender persons who have hysterectomies might foresee, does not preclude the Catholic
14
institution from using the very same act for

different purposes, both proximate and remote. The Catholic provider is not
Moreover, for the same reasons, the fact that in
any given case the procedure might be only one perpetuating or joining in on a
part of a larger process of gender transition lie or a delusion, but rather is
involving additional surgeries that is reasonably
foreseen by the Catholic institution does not treating the suffering of
establish an explicit or implicit intention or individuals by morally legitimate
approval by the institution for that process and
its parts, even if actions carried out in the means.
Catholic institution indirectly affect the primary
sex characteristics .62
characteristics in the treatment of gender
IDENTIFICATION OF AND RESPONSE TO dysphoria or on primary characteristics because
ASSUMPTIONS of a pathophysiological condition and acts
within ethical parameters presented here, it is
The distinction between primary and secondary not trying to change the sexual identity of
sex characteristics as it relates to Catholic persons, nor does it agree with the erroneous
teaching on the creation of the human person is view of sexuality held by the patient. The
also ethically significant for addressing what I Catholic provider is not perpetuating or joining
believe are some erroneous views about the in on a lie or a delusion, but rather it is treating
involvement of Catholic health care in the the suffering of individuals by morally
treatment of gender dysphoria. One such view legitimate means.
argues that any surgical or hormonal
intervention on any sex characteristic–primary Questions about cooperation also need to be
or secondary–to treat gender dysphoria is to addressed.64 First, it is not clear that a person
deny God’s act of creating the body/soul unity suffering from gender dysphoria and seeks
of the human person, and “perpetuates the lie” relief by modification of the secondary sex
that sexual identity can be changed. This view characteristics legitimately qualifies as a
assumes the very thing in need of proof. The principal agent in whose wrongdoing a Catholic
erroneous assumption in play here is that the health care institution cooperates. However,
integral role of sexual identity for the assuming for the sake of argument that the
body/soul unity of the individual human gender dysphoria patient is a principal agent,
person is fully and equally present in all sex there still would be no illicit cooperation in
characteristics.63 It is only the primary sex providing treatment affecting secondary sex
characteristics that are the sufficient condition characteristics. There are several factors that
for the individuation of the body/soul unity in would preclude formal cooperation by a
the creation of particular person as female or Catholic health care institution: (1) treating
male. gender dysphoria involving secondary sex
characterizes can be considered morally good
Moreover, when an institutional Catholic health through an application of the principle of
care provider acts on secondary sex totality; (2) directly treating a pathophysiological
15
condition or risk of one can be justified mandates are government-originated and

through an application of the principle of the controlled and because they represent
double effect; and (3) in such cases foreseeing that significant duress, there may be warrant to
the interventions will indirectly assist a person conclude that the Catholic health care
in gender transition is not intending gender institution does not engage in formal
transition. Allowing treatment affecting the cooperation by complying with the mandates.
secondary sex characteristics to relieve suffering The involvement of third party administrators
constitutes neither formal nor immediate is also an important factor in reducing the risk
material cooperation in gender transition, either of illicit cooperation. While providing insurance
with respect to treatment affecting secondary coverage under these circumstances would be
sex characteristics or any future surgeries traditionally described as “necessary
involving the primary sex characteristics. As for cooperation” (since without the insurance the
interventions affecting the secondary sex procedure would probably not occur), this does
characteristics, there would be no immediate not entail that the cooperation is illicit.
material cooperation because what are essential Although the insurance contributes to the
circumstances from the patient’s perspective occasion of the procedure it does not represent
for gender transition are from the institution’s a condition specific to the performance of the
perspective essential only for relieving the action per se, and therefore is not evidence of an
suffering of gender dysphoria. If there is any intention for approval of the procedure.
cooperation at all, it would be remote, mediate,
material cooperation for a justified reason. Providing objective medical information about
treatment for gender dysphoria, or transferring
With respect to insurance coverage, any the general care of patients with gender
coverage that involves gender dysphoria dysphoria, does not constitute illicit
identified in diagnostic codes, or any use of cooperation or an illicit referral. Such actions
utilization management documentation that do not constitute the specific conditions that
refers to guidelines for treatment of gender have an intrinsic relation to acts of sex
dysphoria for interventions affecting secondary reassignment that would establish an intention
sex characteristics, does not constitute illicit for those actions. Moreover, transferring a
cooperation. The object, intention, and patient to a specialty center for the treatment of
circumstances of such actions are directed gender dysphoria does not of itself contain the
toward the treatment of the dysphoria by specificity to establish an intention or approval
means that do not undermine the sexual by an institution of an attempt to change sexual
identity component integral to the body/soul identity. Likewise, ensuring standards regarding
unity of the person. patient preferences in personal health
information or other accommodations for all
The reality of government mandates affecting transgender persons does not constitute illicit
coverage for interventions involving the cooperation on the part of Catholic health care.
primary sex characteristics solely and only for Such actions include education of staff, use of
treatment of gender dysphoria is a significant preferred gender pronouns, appropriate room
factor for evaluating the ethics of this coverage assignments, accurate information and correct
within Catholic organizations. Because such identification in the EMR, fully informed plans
16
of care, and accurate communication and

ordering on behalf of the patient. These kinds Consistent with Pope Francis’ distinction, to
of actions do not establish the specific treat the suffering of people with gender
conditions with an intrinsic relation that makes dysphoria in accordance with Catholic teaching
possible the performance of removing sex does not entail an acceptance or approval of
characteristics integral to the individuation of a ideologies of gender that are contrary to that
particular person as male or female, nor are teaching. The Congregation for Catholic
they essential. What they do is offer Education makes an important distinction that
compassionate and respectful care directed at bishops, ethicists, theologians, and leaders of
the suffering of these patients. To argue that Catholic health care would do well to consider:
such actions constitute illicit cooperation “If we wish to take an approach to the question
misconstrues the relation between foreseeing of gender theory that is based on the path of
and intending with respect to alleviating dialogue, it is vital to bear in mind the
suffering through hormonal or surgical distinction between the ideology of gender on
treatment and the gender transition of the the one hand, and the whole field of research
patient. As a result of this problem, there is a on gender that the human sciences have
risk that the principle of cooperation in general undertaken, on the other.”66 Not all listening,
will be misconstrued as the prohibition of any reasoning, and proposing on the question of
association with wrongdoing. treating gender dysphoria is ipso facto condoning
or promoting gender ideology.
CONCLUSION
Moreover, there is a real possibility that some
The evaluation of this argument should be might dismiss any attempt to justify care and
made strictly on its merits. It should not be treatment of persons with gender dysphoria
prejudiced by the fact that there exists a gender within the parameters of Catholic teaching on
ideology that rejects a binary view of gender the grounds that such patients may support this
and sexual identity. Any consideration of the ideology and be a cause of theological scandal.
analysis provided here needs to recognize the However, to hold such a view is contrary to
independence of its merits from any societal accepted and justified practices within Catholic
ideology of this sort. The case for the health care. Consider the fact that Catholic
conclusion of this analysis is carefully built on health care does not prohibit the care of
existing evidence about gender dysphoria and a patients with racist beliefs simply because they
faithful presentation and application of Catholic subscribe to an ideology that is antithetical to
teaching and tradition. Pope Francis makes a Catholic teaching, or because there would be a
distinction between being “understanding of perceived approval of that ideology. Although
human weakness and the complexities of life” these two cases are different in that treatment
and responding to “what are at times for a racist patient would have no direct
understandable aspirations” associated with relation to racism itself, to refuse care to such a
persons in gender transition on the one hand, patient based on a perceived connection to
and, on the other, accepting “ideologies that ideology would be the same in both cases.
attempt to sunder what are inseparable aspects Similarly, just as the respectful treatment of gay
of reality.”65 individuals within Catholic institutions is not a
17
cause of theological scandal regarding Catholic continued dialogue about how Catholic health
teaching on human sexuality, so too it is not care can work to alleviate the suffering of
necessarily a legitimate cause of scandal that persons with gender dysphoria and generally
Catholic health care provides treatment for give care to transgender persons consistent with
gender dysphoria simply because there is a that teaching. 68
gender ideology whose tenets are contrary to
Catholic teaching. The inherent human dignity
of these patients requires a more fair PETER J. CATALDO, Ph.D.
consideration. Senior Vice President, Theology and Ethics
Providence St. Joseph Health
When approaching the issue of caring for Renton, WA
persons with gender dysphoria in Catholic [email protected]
health care we do well to apply the teaching of
Pope Francis. He taught that we should “avoid
a cold bureaucratic morality in dealing with
more sensitive issues . . . for although it is quite
true that concern must be shown for the
integrity of the Church’s moral teaching, special
care should always be shown to emphasize and
encourage the highest and most central values
of the Gospel, particularly the primacy of
charity as a response to the completely
gratuitous offer of God’s love.”67 Using the
distinction between the primary and secondary
sex characteristics in the way I am suggesting is
not to deny or ignore the reality of biological
variation in sex, or the very real psychological
and social dimensions of how transgender
persons view themselves. Catholic health care
responds to that experience and to those who
suffer from gender dysphoria as it responds to
any need or request—from its institutional
conscience. This conscience rests in part upon
Catholic teaching on the creation of the human
person as either female or male. The argument
here for the ontological significance of the
distinction between the sex characteristics
recognizes the reality of Catholic teaching and
attempts to reconcile that teaching with the
Catholic theological, metaphysical, and moral
traditions and relevant science. The hope of
this approach is that a path might emerge for
18
Creating Dialogue
1. How would you summarize the key points of Cataldo’s argument?
2. The principle of totality is used widely in health care ethics (e.g. everytime
surgery is performed). Do you agree that it can be applied to transgender
interventions as well (p.9-10)?
3. Can you think of other cases in which subjective suffering justifies medical
intervention?
ENDNOTES
1The Congregation for Catholic Education (CCE) in its “Male and 4 Catechism, 369,
Female He Created Them” Towards A Path of Dialogue on the Question of http://www.vatican.va/archive/ENG0015/__P1B.HTM.
Gender Theory in Education (February 2, 2019, n. 11) states that “it is 5 Catechism, 369,
clear that sex and gender are no longer synonyms or http://www.vatican.va/archive/ENG0015/__P1B.HTM.

interchangeable concepts, since they are used to describe two 6 Catechism, 2331,
different realities. . . . The problem here does not lie in the http://www.vatican.va/archive/ENG0015/__P1B.HTM.
distinction between the two terms, which can be interpreted 7 St. John Paul II, Apostolic Exhortation Christifideles Laici,
correctly, but in the separation of sex from gender.” December 30, 1988, 50, http://w2.vatican.va/content/john-paul-
2 Catechism of the Catholic Church, 365, ii/en/apost_exhortations/documents/hf_jp-
http://www.vatican.va/archive/ENG0015/__P1B.HTM. See ii_exh_30121988_christifideles-laici.html. Additional confirmation
Vatican II, Gaudium et spes, 14: “Though made of body and soul, of the ontological basis of this anthropology is found in the
man is one”; Fourth Lateran Ecumenical Council, Chapter 1, The connection made by him between this anthropology and “the
Catholic Faith, DS 800: “the human creature [is] . . . composed of whole history of salvation.” See also St. John Paul II, Apostolic
spirit and body.” Letter Mulieris Dignitatem, August 15, 1988, 1, 6, 10,
http://www.vatican.va/archive/hist_councils/ii_vatican_council/d http://w2.vatican.va/content/john-paul-
ocuments/vat-ii_const_19651207_gaudium-et-spes_en.html; see ii/en/apost_letters/1988/documents/hf_jp-
also n. 3; First Vatican Ecumenical Council, c. 1: “. . . humanam ii_apl_19880815_mulieris-dignitatem.html.
quasi communem ex spiritu et corpore constitutam,” 8 For a sampling of Thomas Aquinas’ view of the principle of
http://www.vatican.va/archive/hist_councils/i-vatican- individuation see Summa Theologica, I, q. 3, a. 3; I, q. 29, a. 2, ad. 3; I,

council/documents/vat-i_const_18700424_dei-filius_la.html; St. q. 75, a. 4; I, q. 76, a. 6; III, q. 77, a. 2; Quaestio disputata de anima, 9.
John Paul II, Evangelium Vitae, 60. See also Jeffrey E. Brower, “Matter, Form, and Individuation” in
3 See Staley, Kevin. New Catholic Encyclopedia, Supplement 2012– Brian Davies and Eleonore Stump, eds., The Oxford Handbook of
2013, Ethics and Philosophy, s.v. “Soul, Human” Farmington Hills, Aquinas (Oxford: Oxford University Press, 2012): 94–100;
MI: Gale Cengage Learning, 2013. Eleonore Stump, Aquinas (New York: Routledge): 47–50.
19
16 For a definition of anencephaly see Merck Manual: Professional

9 See St. Thomas Aquinas, Quaestiones Disputatae de Anima, a. 12, ad Version (Kenilworth, NJ: Merck Sharp & Dohme Corporation,
7: “There are three genera of accidents: some are caused by the 2018): “Anencephaly is absence of the cerebral hemispheres. The
principles of the species, and are called proper accidents, for absent brain is sometimes replaced by malformed cystic neural
example, risibility in man; others are caused by the principles of the tissue, which may be exposed or covered with skin. Parts of the
individual, and this class is spoken of [in two ways]: first, those that brain stem and spinal cord may be missing or malformed. Infants
have a permanent cause in their subject, for example, masculine are stillborn or die within days or weeks,”
and feminine, and other things of this kind, and these are called https://www.merckmanuals.com/professional/pediatrics/congenit
inseparable accidents; secondly, those that do not have a permanent al-neurologic-anomalies/anencephaly.
17 Cardinal Joseph Ratzinger, “Concerning the Notion of Person in
cause in their subject, such as to sit and to walk, and these are
called separable accidents. Now no accident of any kind ever Theology,” Communio 17 (1990): 439–454 at 542; see also Daniel
constitutes part of the essence of a thing, and thus an accident is Daly, “Who Counts as a Person?” in Incarnate Grace: Perspectives on the
never found in a thing’s definition. Hence we understand the Ministry of Catholic Health care, ed. Charles Bouchard, O.P. (St. Louis,
essence (quod quid est) of a thing without thinking of any of its MO: Catholic Health Association of the United States): 89–91.
18 Catechism, 371.
accidents. However, the species cannot be understood without the 19 Catechism, 2331.
accidents which result from the principles of the species [i.e., the 20 Catechism, 2332; see also Catechism, 2333, 2334, 2335, 370, 372,
proper accidents], although the species can be understood without
the accidents of the individual, even the inseparable accidents. 2337.
21 St. John Paul II, Letter to Women, June 29, 1995, 7,
Indeed, there can be not only a species but also an individual
without the separable accidents. Now the powers of the soul are http://w2.vatican.va/content/john-paul-
accidents in the sense of properties. Therefore, although the ii/en/letters/1995/documents/hf_jp-
essence of the soul is understood without them, still the existence ii_let_29061995_women.html. The use of multiple texts from the
of the soul is neither possible nor intelligible without them.” See Catechism in this analysis is important for two reasons. First, the
also Aquinas, De Ente et Essentia, 6: “Among the accidents that are Catechism is formally recognized “as a full, complete exposition of
consequences of matter there is found a certain diversity. Some Catholic doctrine,” and as a “genuine, systematic presentation of
accidents follow from the order the matter has to a special form, as the faith and of Catholic doctrine” (St. John Paul II, Apostolic
the masculine and the feminine in animals, the difference between Letter, Laetamur Magnopere, August 15, 1997,
which is reduced to the matter, as the Philosopher says in X http://w2.vatican.va/content/john-paul-
Metaphysicae cap. 9 (1058b21-23),” ii/en/apost_letters/1997/documents/hf_jp-
https://sourcebooks.fordham.edu/basis/aquinas-esse.asp, trans. ii_apl_15081997_laetamur.html). Second, in addition to quoting
Robert T. Miller; see also Elliott Louis Bedford and Jason T. Eberl, from key scriptural passages, the texts provide critical linguistic and
“Actual Human Persons Are Sexed, Unified Beings,” Ethics & conceptual precision.
22 CCE, “Male and Female He Created Them” Towards A Path of
Medics 42, (2017): 1–3.
10 See Kevin Fitzgerald, S.J., “Viewing the Transgender Issue from Dialogue on the Question of Gender Theory in Education, n. 31; see also ns.
Catholic and Personalized Health care Perspectives,” Health care 4, 10, 21, 27–28, 32–36.
23 For a biological explanation of the primary and secondary sex
Ethics USA, 24 (2016): 7–10 at 7.
11 AL 286 and 56. characteristics, see “Sex” at
12 For a definition of these conditions see I. A. Hughes, C. Houk, S. http://genderedinnovations.stanford.edu/terms/sex.html. It is
F. Ahmed, P. A. Lee, and LWPES1/ESPE2 Consensus Group, important to note that while the secondary sex characteristics are
“Consensus Statement on Management of Intersex Disorders,” essential for mating, this fact does not make the secondary sex
Archives of Disease in Childhood, 91(2006): 554–563 at 554, characteristics integral to being male or female qua God’s creative
http://dx.doi.org/10.1136/adc.2006.098319: “congenital act, but rather makes them integral qua propagation of the species.
conditions in which development of chromosomal, gonadal, or Having primary sex characteristics sufficient to be created as female
anatomical sex is atypical.” See Ieuan A Hughes, John D Davies, or male is not the same as being able to mate as male or female.
Trevor I Bunch, Vickie Pasterski, Kiki Mastroyannopoulou, Jane The fact that the two types of sex characteristics are related with
MacDougall, “Androgen insensitivity syndrome,” Lancet 380 (2012), respect to mating does not entail that they are the same with
1419: “Androgen insensitivity syndrome in its complete form is a respect to the ontological dimension of God’s creative act.
24 The bodily location of the primary and secondary sex
disorder of hormone resistance characterised by a female
phenotype in an individual with an XY karyotype and testes characteristics also has no relevance to integral status of the
producing age-appropriate normal concentrations of androgens. primary sex characteristics for God’s creative act qua ontological
Pathogenesis is the result of mutations in the X-linked androgen reality.
25 This view also does not entail that everybody’s gender identity is
receptor gene . . . .,” http://dx.doi.org/10.1016/S0140-
6736(12)60071-3. called into question. To assert this is to assume that gender identity
13 See Elliott Louis Bedford and Jason T. Eberl, “Is the Soul Sexed? is determined by each individual’s sense and that God does not
Anthropology, Transgenderism, and Disorders of Sex create each individual as female or male independent of an
Development,” Health care Ethics USA, 24 (2016): 18–33 at 21. individual’s sense.
26 The thesis argued here does not entail that there is a moral
Dialogue on the Question of Gender Theory in Education, n. 23. obligation not to remove the uterus and ovaries of a person with AIS,
15 See, for example, Luke Timothy Johnson, The Revelatory Body: and conversely it does not entail that there is a moral obligation to
Theology as Inductive Art (Cambridge: William B. Eerdmans, 2015): remove these organs because the person has the primary sex
180–188.
20
Transgender Sample: Frequency and Associated Symptoms,”

characteristic of male chromosomes. Such an inference is an Traumatology 17 (2011): 56–67,
attempt at reductio ad absurdum argumentation but can succeed only https://doi.org/10.1177/1534765610395614; and Gia Chodzen,
by assuming the very thing in need of proof; namely, that individual Marco A. Hidalgo, Diane Chen, and Robert Garofalo “Minority
variation in physical sex and gender awareness precludes an Stress Factors Associated with Depression and Anxiety among
ontological dimension to the creation of the human person as male Transgender and Gender-Nonconforming Youth,” Journal of
or female, and, additionally, that there is a moral obligation for a Adolescent Health 64, 4 (2019): 467-471. There is also evidence that
person with AIS to have only one set of primary sex characteristics. transgender persons suffer higher rates of disability and multiple
Neither of these assumptions is true. chronic conditions; see, for example, Janelle M. Downing, and Julia
27 American Psychiatric Association, Diagnostic and Statistical Manual M. Przedworski, “Health of Transgender Adults in the U.S., 2014–
of Mental Disorders (5th ed.), “Gender Dysphoria in Adolescents and 2016,” American Journal of Preventive Medicine 55, 3 (2018): 336–344.
34 See, for example, Cecilia Dhejne, Roy Van Vlerken, Gunter
Adults” (2013), 302.85 (F64.0).
28 Ellen Marshall, Laurence Claes, Walter Pierre Bouman, Gemma Heylens and Jon Arcelus, “Mental Health and Gender Dysphoria:
L. Witcomb and Jon Arcelus, “Non-Suicidal Self-Injury and A Review of the Literature,” 53–54; Gunter Heylens et al., 154;
Suicidality in Trans People: A Systematic Review of the Literature,” Tim C. van de Grift, Els Elaut, Susanne C. Cerwenka, Peggy T.
International Review of Psychiatry, Cohen-Kettenis and Baudewijntje P. C. Kreukels, “Surgical
28 (2016): 58-69, Satisfaction, Quality of Life, and Their Association After Gender-
https://doi.org/10.3109/09540261.2015.1073143. Affirming Surgery: A Follow-up Study,” Journal of Sex & Marital
29 Ellen Marshall et al., “Non-Suicidal Self-Injury and Suicidality in Therapy 44 (2018): 138-148,
Trans People: A Systematic Review of the Literature,” 66. https://doi.org/10.1080/0092623X.2017.1326190; and Marco
30 Cecilia Dhejne, Roy Van Vlerken, Gunter Heylens and Jon Colizzi, Rosalia Costa, and Orlando Todarello, “Dissociative
Arcelus, “Mental Health and Gender Dysphoria: A Review of the Symptoms in Individuals with Gender Dysphoria: Is the Elevated
Literature,” International Review of Psychiatry 28 (2016): 44-57 at 52, Prevalence Real?” Psychiatry Research, 226, 1 (2015): 173-180.
35 Rosalia Costa and Marco Colizzi, “The Effect of Cross-Sex
https://doi.org/10.3109/09540261.2015.1115753; see also Edward
McCann and Danika Sharek, “Mental Health Needs of People Who Hormonal Treatment on Gender Dysphoria Individuals’ Mental
Identify as Transgender: A Review of the Literature,” Archives of Health: A Systematic Review,” Neuropsychiatric Disease and Treatment
Psychiatric Nursing 12 (2016): 1953–1966 at1964,
30, 2 (April 2016): 280-28. http://doi.org/10.2147/NDT.S95310; see also Hiroyuki Oda and
31 Ann P. Haas, Philip L. Rodgers, and Jody L. Herman, Suicide Toshihiko Kinoshita, “Efficacy of Hormonal and Mental
Attempts among Transgender and Gender Non-Conforming Adults, The Treatments with MMPI in FtM Individuals: Cross-Sectional and
Williams Institute, (2014): 1–18 at 2, Longitudinal Studies.” BMC Psychiatry 17 (2017): 1–8,
https://williamsinstitute.law.ucla.edu/research/suicide-attempts- http://doi.org/10.1186/s12888-017-1423-y; Mohammad Hassan
among-transgender-and-gender-non-conforming-adults/; S.E. Murad, Mohamed B. Elamin, Magaly Zumaeta Garcia, Rebecca J.
James, J.L. Herman, S. Rankin, M. Keisling, L. Mottet, and M. Mullan, Ayman Murad, Patricia J. Erwin, and Victor M. Montori,
Anafi, Executive Summary of the Report of the 2015 U.S. Transgender “Hormonal Therapy and Sex Reassignment: A Systematic Review
Survey (Washington, DC: National Center for Transgender Equality, and Meta-Analysis of Quality of Life and Psychosocial Outcomes,”
2016), http://www.ustranssurvey.org/reports#USTS. Clinical Endocrinology 72 (2010): 214–231; AudreyGorin‐Lazard,
32 Gunter Heylens, Els Elaut, Baudewijntje P. C. Kreukels, Muirne Karine Baumstarck, LaurentBoyer, Aurélie Maquigneau, Stéphanie
C. S. Paap, Susanne Cerwenka, Gebleux, Jean‐Claude Penochet, Dominique Pringuey, Frédérique
Hertha Richter-Appelt, Peggy T. Cohen-Kettenis, Ira R. Haraldsen Albarel, IsabelleMorange, AndersonLoundou, JulieBerbis, Pascal
and Griet De Cuypere, “Psychiatric Characteristics in Transsexual Auquier, Christophe Lançon, and Mireille Bonierbale, “Is
Individuals: Multicentre Study in Four European Countries,” The Hormonal Therapy Associated with Better Quality of Life in
British Journal of Psychiatry 204 (2014): 151-156 at 154, Transsexuals? A Cross‐Sectional Study,” The Journal of Sexual
https://doi.org/10.1192/bjp.bp.112.121954; see also Gemma L. Medicine 9, 2 (February 2012): 531-541; Esther Gómez-Gil, Leire
Witcomb, Walter Pierre Bouman, Laurence Claes, Nicola Brewin, Zubiaurre-Elorza, Isabel Esteva, Antonio Guillamon, Teresa
John R. Crawford, Jon Arcelus, “Levels of Depression in Godás, M. Cruz Almaraz, Irene Halperin, Manel Salamero,
Transgender People and Its Predictors: Results of A Large Matched “Hormone-Treated Transsexuals Report Less Social Distress,
Control Study with Transgender People Accessing Clinical Anxiety and Depression,” Psychoneuroendocrinology, 37, 5 (2012): 662-
Services,” Journal of Affective Disorders 235 (2018): 308–315; and 670; Marco Colizzi, Rosalia Costa, and Orlando Todarello,
Sarah E. Valentine, and Jillian C. Shipherd, “A Systematic Review “Transsexual Patients’ Psychiatric
of Social Stress and Mental Health Among Transgender and Comorbidity and Positive Effect of Cross-Sex Hormonal
Gender Non-Conforming People in the United States,” Clinical Treatment on Mental Health: Results From A Longitudinal Study,”
Psychology Review 66 (December 2018): 24-38. Psychoneuroendocrinology 39, (2014): 65–73.
33 Walter O. Bockting, Michael H. Miner, Rebecca E. Swinburne 36 Wylie C. Hembree, Peggy T. Cohen-Kettenis, Louis Gooren,
Romine, Autumn Hamilton, and Eli Coleman, “Stigma, Mental Sabine E. Hannema, Walter J. Meyer, M. Hassan Murad, Stephen
Health, and Resilience in an Online Sample of the US Transgender M. Rosenthal, Joshua D. Safer, Vin Tangpricha, and Guy G.
Population,” American Journal of Public Health 103 (2013): 943–951 at T’Sjoen, “Endocrine Treatment of Gender-Dysphoric/Gender-
948, http://doi.org/10.2105/AJPH.2013.301241; see also Jillian C. Incongruent Persons: An Endocrine Society Clinical Practice
Shipherd, Shira Maguen, W. Christopher Skidmore and Sarah M. Guideline,” The Journal of Clinical Endocrinology Metabolism 102 (2017):
Abramovitz, “Potentially Traumatic Events in a 3869–3903 at 3895, https://doi.org/10.1210/jc.2017-01658; see
21
except this: where the relationship of whole to part is verified, and

also Ebba K. Lindqvist, Hannes Sigurjonsson, Caroline in the exact degree to which it is verified, the part is subordinated
Möllermark, Johan Rinder, Filip Farnebo, and T. Kalle Lundgren, to the whole, which latter can in its own interest dispose of the
“Quality of Life Improves Early After Gender Reassignment part” (ibid.). Notice that Pius specifies the “principle of totality
Surgery in Transgender Women,” European Journal of Plastic Surgery itself” indicating that it is not reducible to one particular kind of
40 (2017):223–226; and Annette Kuhn, Christine Bodmer, Werner application.
41 See Becket Gremmels, “Sex Reassignment Surgery and the
Stadlmayr, Peter Kuhn, Michael D. Mueller, and Martin Birkhäuser,
“Quality of Life 15 Years After Sex Reassignment Surgery for Catholic Moral Tradition: Insight from Pope Pius XII on the
Transsexualism,” Fertility and Sterility 92, 5 (November 2009): 1685– Principle of Totality,” Health care Ethics USA 24 (2016): 6–10, and
1689. “More Insight from Pius XII, a Reply to Brugger and Brehany, and
37 Simonsen RK Giraldi A E Hald, GM, “Long-Term Follow-Up of a Clarification,” Health care Ethics USA 24 (2016): 7–17.
42 See Benedict Ashley, O.P., Theologies of the Body: Humanist and
Individuals Undergoing Sex Reassignment Surgery: Psychiatric
Morbidity and Mortality,” Nordic Journal of Psychiatry 70 (2016): 241- Christian, Pope John XXIII Medical-Moral Research and Education
247 at 246, https://doi.org/10.3109/08039488.2015.1081405; see Center (Braintree, MA: The Pope John Center, 1985): 422 on the
also, Chantal M.Wiepjes, Nienke M.Nota, Christel J.M.de Blok, differentiation between actions justified by principle of totality and
MaartjeKlaver, Annelou L.C.de Vries, S. AnnelijnWensing-Kruger, those not justified by the principle. Under the principle, the fact
Renate T.de Jongh, Mark-BramBouman, Thomas D.Steensma, that “a non-essential part is sacrificed for the sake of the whole”
PeggyCohen-Kettenis, Louis J.G.Gooren, Baudewijntje P.C. ought not to be confused with an action in which “an essential part
Kreukels, and Martinden Heijer, “The Amsterdam Cohort of . . . is sacrificed not for the sake of the whole but for the sake of
Gender Dysphoria Study (1972–2015): Trends in Prevalence, another part, with injury to the whole.” Consistent with this
Treatment, and Regrets,” The Journal of Sexual Medicine 15, 4, (April distinction is the fact that sacrificing the primary sex characteristics
2018): 582-590, https://doi.org/10.1016/j.jsxm.2018.01.016; Tim precisely as such is sacrificing an essential part while doing injury to
C. van de Grift, Els Elaut, Susanne C. Cerwenka, Peggy T. Cohen- the whole.
43For recognition of the potential sterilizing effects of hormone
Kettenis, Griet De Cuypere, Hertha Richter-Appelt, and
Baudewijntje P.C. Kreukels, “Effects of Medical Interventions on therapy see Hembree et al, “Endocrine Treatment of Gender-
Gender Dysphoria and Body Image: A Follow-Up Study,” Dysphoric/Gender-Incongruent Persons: An Endocrine Society
Psychosomatic Medicine, 79 (September 2017): 815-823; Tim C. van de Clinical Practice Guideline,” 3869–3903. Some make the claim that
Grifta, Els Elautb, Susanne C. Cerwenkac, Peggy T. Cohen- puberty suppressing drugs are fully reversible and that feminizing
Kettenisd, and Baudewijntje P. C. Kreukelsd, “Surgical Satisfaction, and masculinizing drugs are partially reversible: see, The World
Quality of Life, and Their Association After Gender-Affirming Professional Association for Transgender Health, Standards of Care
Surgery: A Follow-up Study,” Journal of Sex & Marital Therapy 44, 2 for the Health of Transsexual, Transgender, and Gender Nonconforming
(2018): 138–148; Grace Poudrier, Ian T. Nolan, Tiffany E. Cook, People 7th Version (2011): 17–20,
Whitney Saia, Catherine C. Motosko, John T. Stranix, Jennifer E. https://www.wpath.org/publications/soc.
44 The fact that levels of each hormone are greater or less
Thomson, M. David Gothard, Alexes Hazen, “Assessing Quality of
Life and Patient-Reported Satisfaction with Masculinizing Top depending upon the sex does not change the fact that the
Surgery: A Mixed-Methods Descriptive Survey Study,” Plastic and hormones are causes of sex characteristics as effects and are not the
Reconstructive Surgery 143, 1 (January 2019): 272-279; T.A. Ainsworth, characteristics themselves. For an explanation of the physiological
and J.H. Spiegel, “Quality of Life of Individuals With and Without functions of testosterone and estrogen respectively see “Male
Facial Feminization Surgery or Gender Reassignment Surgery,” Reproductive Endocrinology,” Merck Manual Professional Version,
Quality of Life Research 19, 7 (2010):1019– 1024; Luk Gijs and Anne https://www.merckmanuals.com/professional/genitourinary-
Brewaeys, “Surgical Treatment of Gender Dysphoria in Adults and disorders/male-reproductive-endocrinology-and-related-
Adolescents: Recent Developments, Effectiveness, and disorders/male-reproductive-endocrinology, and “Female
Challenges,” Annual Review of Sex Research, 18,1 (2007): 178-224. Reproductive Endocrinology,” Merck Manual Professional Version,
38 Cecilia Dhejne, Paul Lichtenstein, Marcus Boman, Anna L. V. https://www.merckmanuals.com/professional/gynecology-and-
Johansson, Niklas Langstrom, Mikael obstetrics/female-reproductive-endocrinology/female-
Landen, “Long-Term Follow-Up of Transsexual Persons reproductive-endocrinology.
45 David Albert Jones, “Gender Reassignment Surgery: A Catholic
Undergoing Sex Reassignment Surgery: Cohort Study in Sweden,”
PLoS ONE 6 (2011): 1–8 at 7, Bioethical Analysis,” Theological Studies 79 (2018): 314–338,
https://doi.org/10.1371/journal.pone.0016885. https://doi.org/10.1177/0040563918766711.
46For Jones’ view, see David Albert Jones, “Gender Reassignment
39 The World Professional Association for Transgender Health,
Standards of Care for the Health of Transsexual, Transgender, and Gender Surgery: A Catholic Bioethical Analysis,” 330–332.
47 The discussion of the principle of totality, and in particular Pius
Nonconforming People 7th Version (2011): 54–55,
https://www.wpath.org/publications/soc.The WPATH Standards XII’s view of it, is not intended to be a complete study of the
do not delineate the types of surgery that it characterizes as “sex concept, nor does it need to be for the purposes of this paper.
48 Pope Pius, XII, Address to the First International Congress of
reassignment surgery.” It must be acknowledged that the studies to
date indicate that hormonal and surgical treatment are effective for Histopathology (September 13, 1952), Monks of Solesmes, ed., The
some but not all individuals suffering from gender dysphoria. Human Body: Papal Teachings, 199.
49 See Becket Gremmels, “Sex Reassignment Surgery and the
40 Pope Pius, XII, Address to the First International Congress of
Histopathology (September 13, 1952), in Monks of Solesmes, ed., Catholic Moral Tradition: Insight from Pope Pius XII on the
The Human Body: Papal Teachings (Boston: Daughters of St. Paul, Principle of Totality,” 8, and Becket Gremmels, “More Insight
1960): 206; see also: “The principle of totality itself affirms nothing
22
O’Brien, Peter J. Cataldo, John Paul Slosar, Mark Repenshek,

from Pius XII, a Reply to Brugger and Brehany, and a Clarification, Douglas Brown, MD, and Susan Caro, RN, “Opportunistic
7–17 for another account of how Pius’ view of the principle is not Salpingectomy to Reduce the Risk of Ovarian Cancer,” National
physicalistic. Catholic Bioethics Quarterly 16 (2016): 99–131,
50 Pope Pius, XII, Address to the First International Congress of https://doi.org/10.5840/ncbq201616110.
61 Aquinas, Summa Theologiae, 1-2, q. 1, a. 3, ad, 3 (hereafter cited as
Histopathology (September 13, 1952), Monks of Solesmes, ed., The
Human Body: Papal Teachings, 199. Pius repeatedly refers to the whole ST); see also ST, 1-2, q. 20, a. 3.
62For an example of the view that contributing to the gender
of the person as inclusive of the powers and operations of body
and soul; see also Pius XII, Address to the Italian Society of Plastic transition process is morally wrong see, Benedict M. Guevin,
Surgery (Oct. 4, 1958). “Augmentation Mammaplasty for Male-to-Female Transsexuals: A
51 See, for example, Pope Pius XII, Address to the Italian Medical- Case Study for Catholic Hospitals, The National Catholic Bioethics
Biological Union of St. Luke (November 12, 1944), Monks of Quarterly 9 (2009): 457–458, https://doi.org/10.5840/20099332.
63 For example, consider this statement: “Given this understanding
Solesmes, ed., The Human Body: Papal Teachings, 55–56.
52Pope Pius, XII, Address to a group of eye specialists (May 14, of what it means to be a human person, a body–soul unity whose
1956), Monks of Solesmes, ed., The Human Body: Papal Teachings, innate sexual identity is reflected in the person’s biology, it should
375. be clear that no surgical, hormonal, or other intervention directed
53 Pope Pius, XII, Address to a group of country doctors (October toward the body is capable of altering that innate sexual identity,”
4, 1953), Monks of Solesmes, ed., The Human Body: Papal Teachings, The National Catholic Bioethics Center, “Brief Statement on
276. Transgenderism,” National Catholic Bioethics Quarterly 16 (2016): 599–
54 Pope Pius, XII, Address to the First International Congress of 603, https://doi.org/10.5840/ncbq201616457. For other
Histopathology (September 13, 1952), Monks of Solesmes, ed., The examples of this fundamental error see John A. Di Camillo,
Human Body: Papal Teachings, 205. “Gender Transitioning and Catholic Health care,” National Catholic
55 Pope Pius, XII, Address to the Italian Medical-Biological Union Bioethics Quarterly 17 (2017): 213–223,
of St. Luke (November 12, 1944), Monks of Solesmes, ed., The https://doi.org/10.5840/ncbq201717221; Edward J. Furton, “A
Human Body: Papal Teachings, 53. Critique of ‘Gender Dysphoria’ in DSM-5,” Ethics & Medics 42
56 This explanation of Pius’ use of these terms resolves what may (2017): 1–4; see also Benedict M. Guevin, “Sex Reassignment
appear to be an inconsistency in the way he understood the Surgery for Transsexuals: An Ethical Conundrum?” The National
principle of totality; for example, Scaria Kanniyakonil, Living Organ Catholic Bioethics Quarterly 5 (2005): 719-734 at 733,
Donation and Transplantation: A Medical, Legal, and Moral Theological https://doi.org/10.5840/ncbq2005547.
64 See, for example, National Catholic Bioethics Center, “Brief
Appraisal (Oriental Institute of Religious studies India, Department
of Publications of Paurastya Vidyapithan, 2005): 164 outlines the Statement on Transgenderism.”
65 Pope Francis, Amoris Laetitia (March 19, 2016), 56,
appearance of this inconsistency.
57 David Albert Jones, “Gender Reassignment Surgery: A Catholic http://w2.vatican.va/content/francesco/en/apost_exhortations/d
Bioethical Analysis,” 336. ocuments/papa-francesco_esortazione-ap_20160319_amoris-
58 David Albert Jones, “Gender Reassignment Surgery: A Catholic laetitia.html (hereafter cited as AL).
Bioethical Analysis,” 331.
59 David Albert Jones, “Gender Reassignment Surgery: A Catholic Dialogue on the Question of Gender Theory in Education, n. 6.
67 Pope Francis, AL, 312 and 311.
Bioethical Analysis,” 331. 68 I am very grateful for the many helpful comments on earlier versions of this
60 See, Pius XII, Address to Delegates at the Twenty-Sixth
Congress of Urology (October 8, 1953), Monks of Solesmes ed., paper, especially those by Dan O’Brien, Ron Hamel, Fr. Charlie Bouchard,
The Human Body: Papal Teachings, 277–279; see also, Colloquium O.P., Dan Dwyer, and the members of the CHA Task Force on Transgender
Participants, “Medical Intervention in Cases of Maternal–Fetal Health.
Vital Conflicts: A Statement of Consensus,” National Catholic
Bioethics Quarterly 14 (2014): 477–489,
https://doi.org/10.5840/ncbq20141439; Becket Gremmels, Dan
23

Catholic Teaching On The Human Person and Gender Dysphoria

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SUMMER 2019 FEATURE ARTICLE

chausa.org/hceusa Catholic Teaching on the Human

Catholic Teaching on the

true that we cannot separate the masculine and

ontological dimension.15 However, to determine

development of the anticipated colleagues “found that trans people attending

CONVERGING INTENTIONS St. Thomas Aquinas addresses this problem

institution from using the very same act for

condition or risk of one can be justified mandates are government-originated and

of care, and accurate communication and

clear that sex and gender are no longer synonyms or http://www.vatican.va/archive/ENG0015/__P1B.HTM.

http://www.vatican.va/archive/hist_councils/i-vatican- individuation see Summa Theologica, I, q. 3, a. 3; I, q. 29, a. 2, ad. 3; I,

16 For a definition of anencephaly see Merck Manual: Professional

Transgender Sample: Frequency and Associated Symptoms,”

except this: where the relationship of whole to part is verified, and

O’Brien, Peter J. Cataldo, John Paul Slosar, Mark Repenshek,

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