"Hi, I'm Nick," the man said as he shook hands with each of us and sat down at the table in the quiet restaurant. There was nothing noteworthy about his appearance. There were no visible signs that Nick is a transgender man who has suffered from gender dysphoria — a medical condition wherein one's gender identity persistently differs from the sex assigned at birth and this discrepancy causes significant distress.
There has been an influx of questions raised in the church and its ministries about people, from children to the elderly, who actively struggle with their gender identity. Unlike other articles we've written, which tend to be more analytical in nature, we wanted to explore and develop our theological perspective on these questions by focusing first on the lives and experiences of people who struggle with gender identity. It is for this reason that we found ourselves sitting with Nick, grateful for his willingness to talk about his experiences and divulge matters ordinarily not shared between newly acquainted people.
Nick told us about the questions, struggles and triumphs of his life. At roughly 10 years old, he sensed that his identity did not accord with the female sex he was assigned at birth. As a young adult, Nick took small steps toward embracing his identity, eventually making a slow and thoughtful decision to undergo a full social transition. Many of his friends and family offered acceptance and affirmation.
Nick also found a sense of security within various groups, including faith communities. In fact, his Catholic faith and participation in the life of the church have grown stronger alongside the overall improvements he experienced with his transition.
For Nick, transition eventually meant seeking medical assistance. He receives hormone therapy and underwent mastectomy, but Nick is not sure that he will ever undergo additional surgeries. His transition is about being true to who he is, and he is not sure that will require additional medical procedures.
While not without challenges, his overall story is one that illustrates the way that self-acceptance, family support, a welcoming faith community, and coordinated, compassionate medical care can help a person find greater wholeness.
However, Nick was quick to acknowledge that his positive physical, social, spiritual and professional experiences are not shared by all transgender people. As we have observed among other transgender people who have been willing to share their stories, transgender individuals have higher than average risks of poverty, harassment, physical and sexual assault, employment and housing discrimination, unemployment, homelessness, and low income. They are disproportionately vulnerable to depression, anxiety, substance abuse and other mental health issues.
These and other factors contribute to the sobering statistic that more than 40 percent of transgender people report a suicide attempt compared to less than 2 percent of the general population.
A significant number of people who are part of the church or engage its ministries are struggling with their gender identity, striving to live authentically and find a place in their churches and communities. In local parishes, transgender individuals attend weekly services. They seek to have roles in the ministry of Word or Eucharist. Some work or volunteer in the social ministries of the church, while others receive aid from these services.
The presence of transgender people within the church and its ministries raises important questions. As a church that seeks to respond to the signs of the times and reach out with openness to vulnerable and marginalized people, we need to think about how we are engaging transgender people and what kind of environment we want to create for those struggling with gender identity.
On the fringes
The fundamental and unifying narrative of the church is the story of God's action in creation and especially in Jesus. The Gospels paint a picture of Jesus reaching out to people, focusing particularly on those who are stigmatized or on the fringes of society because of physical, religious, economic or behavioral reasons.
In word and action, Jesus transforms the lives of people who experience suffering, doubt, isolation, rejection and illness by restoring them to wholeness and bringing them back into the fullness of community life. In the process, he shares a message about God's mercy and the transformative power of God's love.
A good example of Jesus' concern for the marginalized is his encounter with a Samaritan woman who comes alone to the communal well to draw water because she is estranged from her community (John 4:7-42). While a Jewish man like Jesus had multiple reasons to avoid her, he reaches out to her with a love that recognizes her worth and goodness. Eventually, because Jesus engages this ostracized Samaritan woman, she returns to the community from which she has been separated and gives a testimony that leads others to believe in Jesus' message.
Jesus' encounter with the Samaritan woman offers two important insights for the church. First, Jesus reaches out with openness to people on the fringes. Second, Jesus is not fixated on what separates one from community; rather, his focus is on the Samaritan woman's overall good or well-being and his actions are directed toward helping her grow in faith, restore broken relationships, and participate more fully in community.
The Samaritan woman, like all of us, has struggles and failures. Yet, Jesus' priority is to reveal God's healing and reconciling presence and affirm that she, too, has a role to play in bringing about the reign of God through her participation in her community.
This story is but one example from the Gospels that suggests a church seeking to be Christ-like and to mediate God's love of humanity must reach out first with openness and compassion, not judgment, to transgender people, who are trying to live authentically. Transgender people like Nick make a courageous and difficult decision to transition, often knowing that it may lead to rejection, exclusion and hurt.
In imitation of Jesus, the first impulse of the church must be to promote greater wholeness for transgender individuals by listening, caring, supporting and offering community. This means, at a minimum, offering very basic gestures of welcoming respect, such as using a person's preferred pronoun and addressing a person with their preferred name, recognizing their intent to live as the person they believe God created them to be, and refraining from judgments that might exacerbate struggles with gender identity.
Too often, the church is a place wherein people who are striving to be true to their identity feel afraid, unwelcome or condemned. In part, hostility and condemnation arise when we focus too narrowly on applying specific moral teachings to the situation and lose sight of the overall good of the person in need of support.
There is no definitive teaching on transgender issues. Even if there were, it could not support treating such individuals in ways that make them feel like outcasts who are beyond the purview of God's love and the church's welcome embrace.
Furthermore, Catholic teaching on other matters of sexuality, such as homosexuality, do not necessarily apply to transgender people, who may be attracted to members of the same or opposite sex or who may feel called to single life and celibacy.
The church must remember the basis of all moral teachings is the Gospels and the example of Jesus, who prioritized unconditional love and compassion over judgment. Pope Francis describes this well in Evangelii Gaudium:
Before all else, the Gospel invites us to respond to the God of love who saves us, to see God in others and to go forth from ourselves to seek the good of others. Under no circumstance can this invitation be obscured! ... If this invitation does not radiate forcefully and attractively, the edifice of the Church's moral teaching risks becoming a house of cards, and this is our greatest risk. It would mean that it is not the Gospel which is being preached, but certain doctrinal or moral points based on specific ideological options. The message will run the risk of losing its freshness and will cease to have "the fragrance of the Gospel."
Offering unconditional love, compassion and respect to people who identify as transgender is a task not only for the church's internal worship, education and fellowship, but also in its ministerial activities. The ministry of Catholic health care faces additional questions about the clinical care of transgender persons who seek transition-related therapies.
The most basic question is whether Catholic health care organizations should provide such therapies to people like Nick, who are often severely hindered in their pursuit of living an honest and authentic life because of the significant effects of gender dysphoria.
A traditional approach might begin to address this question by applying principles and norms that have developed from a Catholic natural law perspective in response to issues surrounding sexuality or surgery. In this line of logic, transition-related therapies might be deemed impermissible because they fundamentally alter one's God-given nature, diminish one's reproductive capacity, or constitute unjustified mutilation.
For example, an orchiectomy in a transgender patient might be deemed impermissible due to the absence of a present and serious pathology. A mastectomy might be considered unethical because some do not view gender dysphoria as a clinical indication for which a part of one's body can legitimately be sacrificed for the good of the whole person.
However, principles and norms about the removal of reproductive organs or other surgeries have evolved in response to very different questions and issues. Extrapolating these natural law principles and norms to judge the moral permissibility of transition-related therapies extends them to a categorically different area than they rightly apply.
If we evaluate transition-related therapies with the natural law approach employed in prominent matters of sexuality and bodily integrity, we run the risk of focusing excessively on the physical and, especially, functional dimensions of transgender persons and could neglect their overall good and need for wholeness and belonging. Additionally, these principles are most easily applied to surgeries, especially sex reassignment surgery, which only a minority of transgender people undertake. These principles are not readily applicable to less invasive forms of treatment, such as hormone therapy, which has proven to be effective in alleviating the symptoms of gender dysphoria.
Before judging transition-related therapies from a natural law perspective, we need to take a step back and think holistically about the complex experiences of transgender people in light of the Gospel.
While the narratives of transgender people are vastly diverse, there is a striking theme within them: Transgender people undertake their transition in pursuit of becoming whole and living authentically across the entirety of their lives. People who transition are seeking to overcome what they experience as an impediment to living, loving and interacting from an authentic place. They are aiming toward the kind of wholeness and integration in body, mind and spirit that Jesus also affirmed in his teaching and healing ministry.
If we think about the human person holistically and if we strive in imitation of Christ to help people flourish as whole, embodied persons, we might feel compelled to think differently about transition-related therapies. Rather than fundamentally altering a transgender person's God-given nature or destroying reproductive function, we might see such therapies as fundamentally aligning the person's body with their sense of self and restoring the person to greater wholeness.
In fact, this is the experience of most transgender individuals who have undertaken transition-related therapies to better integrate their embodied experience as human persons. When Nick underwent hormone therapy and mastectomy, for instance, he was finally able to gain a better sense of unity about himself as a physical, psychological, relational and spiritual person. While his transition is an everyday process, these therapies enabled him to align his identity and integrate his sense of the person he knows he is within his appearance, interactions and relationships.
Certainly, the provision of transition-related therapies requires a cautious approach that begins with counseling and conservative management. Diagnosis of gender dysphoria should be made over time to rule out confounding factors. A multidisciplinary team with expertise in treating transgender people should collaborate in coordinating the care across the continuum rather than providing treatment episodically.
Whether transition-related therapies are needed at all and which therapies are necessary to help a person experience adequate alignment and integration are decisions that should be made on a case-by-case basis by the individual in consultation with the medical team. Some transgender persons may feel therapy is necessary, whereas others may determine it is not required for their transition.
However, when people are persistent in the gender that they affirm and over time have gained substantive evidence that one or more transition-related therapies is necessary to help them thrive, such therapies should be offered with the intent of aligning the nature of the person. In our view, transition-related therapies, under conditions such as these, can be an appropriate manifestation of the healing ministry of Jesus aimed at restoring the person to wholeness and the fullness of community life.
Like all people, transgender individuals come to the church and its ministries in need of acceptance, compassion, love and care. They are often seeking shelter and support on the all-too-often lonely and confusing journey on which they find themselves.
Because the causes of gender dysphoria are not well understood and transgender persons may challenge our conception of sex and gender, our first inclination might be to judge, even condemn. However, the Gospel calls us to love and be of service to these vulnerable and often marginalized individuals who are striving to be true to who they believe they are and are called to be.
Francis' words, offered in a different context, capture this well. As he said in a homily in Havana Sept. 20, 2015:
The call to serve involves something special, to which we must be attentive. Serving means caring for their vulnerability. Caring for the vulnerable of our families, our society, our people. Theirs are the suffering, fragile and downcast faces which Jesus tells us specifically to look at and which he asks us to love. With a love which takes shape in our actions and decisions. With a love which finds expression in whatever tasks we, as citizens, are called to perform. It is people of flesh and blood, people with individual lives and stories, and with all their frailty, that Jesus asks us to protect, to care for and to serve. Being a Christian entails promoting the dignity of our brothers and sisters, fighting for it, living for it.
As a church and through its ministries, we are called to reach out to transgender persons with a love through which God's healing and reconciling presence may be revealed. If we fail in this task, we fail the test of the Gospel.
[Rachelle Barina has a doctorate in health care ethics from St. Louis University and is a theologian and ethicist working in Catholic health care. Michael Panicola has a doctorate in health care ethics from St. Louis University and is also a theologian and ethicist working in Catholic health care. Ron Hamel has a doctorate in theological ethics from Fordham University and is a retired theologian and ethicist who previously worked as a senior ethicist.]