Saturday, February 12, 2011

The Case of the Sexual Reassignment Patient


    The issue of sexual reassignment surgery is one which is problematic for many different religious denominations.  This article deals with the case of a 32 year old from Tennessee who underwent such surgery after two years of psychotherapy.  As pastoral care providers, we have a responsibility to minister to the needs of such persons in a way that is not judgmental, but helps them to come to realization that they are truly loved by God.   The theological concept of “incarnation” and the pastoral function of “sustaining” appears to fit this person’s situation quite well.  I also speak of the role of the pastoral care provider as “interpretive guide” in terms of helping his or her congregation to become a more loving and caring community so that they can reach out to such people and give witness to the presence of God in the person’s life.  

    [1] Ministerial incident: The gentleman is a 32 year old Certified Public Accountant from Tennessee who has "always felt like a woman trapped in a man's body". He is from a very devout Presbyterian family and had received very little support from friends or family regarding his decision to undergo sexual reassignment surgery (SRS). He underwent the surgery last year, after undergoing two years of psychotherapy, and is now living his life as a woman. In a telephone conversation with him in September 2007, he spoke of his difficulty regarding being accepted by those who used to know him before the surgery.  In fact, a number of clients have refused to use him as their company auditor since he underwent the surgery.  
    [2] Magisterial Teachings: Two groups of magisterial teachings apply to this case: those on the dignity of the human person and those on the mutilation of the body.
Concerning the Dignity of the Human Person
The teachings of the Second Vatican Council reiterate the Church's long-standing teaching on the inherent dignity of the human person. It is stated on five different occasions - three of the most important statements are stated as follows:
    Gaudium et Spes (7 December 1965) is a pastoral constitution. It was addressed primarily as a statement regarding the Church's position within the modern world. Since it is a pastoral rather than a dogmatic constitution, some of its teachings are not of the highest conciliar authority; however, its teaching on the dignity of the human person appears to be within the realm of doctrinal teaching since it reaffirms a long-standing Church teaching on this subject.  It is addressed in Sections 12, 14, and 27 of the document.

Persona Humana is the Sacred Congregation for the Doctrine of the Faith's declaration regarding certain questions concerning sexual ethics. It was issued on 12/29/75 and states:

3. These fundamental principles, which can be grasped by reason, are contained in "the divine law - eternal, objective, and universal - whereby God orders, directs, and governs the entire universe and all the ways of the human community, by a plan conceived in wisdom and love. Man has been made by God to participate in this law, with the result that, under the gentle disposition of divine providence, he can come to perceive ever increasingly the unchanging truth." (DH 3) This divine law is accessible to our minds. 1

The Catechism of the Catholic Church (CCC) addresses the issue of the issue of the dignity of the human person the CCC #1700 and #1706.
    In its December 8, 1995 document "Truth and Meaning of Human Sexuality", the Pontifical Council for the Family stated,

8. As the image of God, man is created for love. This truth was fully revealed to us in the New Testament, together with the mystery of the inner life of the Trinity; "'God is love (1 Jn 4:8) and in himself he lives a mystery of personal loving communion. Creating the human race in his own image…, God inscribed in the humanity of man and woman the vocation, and thus the capacity and responsibility of love and communion. Love is therefore the fundamental and innate vocation of every human being." (FC 11). The whole meaning of true freedom, and self-control which follows from it, is thus directed toward self-giving in communion and friendship with God and with others.2

 The teaching on the dignity of man is also affirmed in the first encyclical of Pope Benedict XVI, Deus Caritas Est (God is Love) #8, which was promulgated on December 25, 2005.
Concerning Mutilation of the Body
   Gaudium et Spes (12/7/65) makes reference to the topic of bodily mutilation in paragraph 27.
   The Instruction on Respect for Human Life in Its Origins and on the Dignity of Procreation (Donum Vitae) #5, a document issued by the Sacred Congregation for the Doctrine of the Faith on February 22, 1987 explicitly states the teaching of the Magisterium in the area of biomedical ethics.
   While this teaching deals specifically with the topic of abortion, the fact that each person bears the divine image can allow us to extend this teaching to include sexual reassignment surgery since the person was created with either a male or female body and they are meant to give glory to God through the conjugal, self-giving act of marital love which can only be accomplished by maintain the integrity of their sexual identity.
    [3] Comparative Theological Views: Here I offer views from two contemporary theological authors on the topics of the dignity of the human person and the mutilation of the body. The first deals with the dignity of the human person (imago Dei) and the second deals with bodily mutilation.
   In his book, Catholic Moral Tradition, Monsignor David A. Bohr, S.T.D. of the Diocese of Scranton, PA, speaks about man being created in the image of God under the heading of Christian Anthropology: The Person "In Christ". Under the heading of "Created in the Image of God", he writes:

We act according to who we are and, even more fundamentally, believe ourselves to be (aqere sequitur esse/credere). Our contemporary pluralistic society gives us any number of options in this particular category. For those who accept biblical revelation, the very first pages of Scripture inform us that God created us in the divine image (see Gen 1:26). This is the basis of human dignity. We mirror the image of God in our rationality, freedom, and capacity for personal relationships. Thomas Aquinas maintained that Christian life or morality meant realizing the image of God within us. This divine image, he maintained, is reflected by the fact we are intellectual beings, having dominion over our actions, and is most perfectly manifested in the practice of charity. 3

The article "Removal of a Healthy Organ" by Pope Pius XII in The Human Body: Papal Teachings (10/8/53) provides the conditions which govern the moral licitness of a surgical operation which causes anatomic or functional mutilation. The Supreme Pontiff states:

First that the continued presence or functioning of a particular organ within the whole organism is causing serious damage or constitutes a menace to it; next, this damage must be remediable or at least can be measurably lessened by the mutilation in question, and the operation's efficacy in this regard should be well assured; finally, one must be reasonably certain that the negative effect, that is, the mutilation and its consequences, will be compensated for by the positive effect: elimination of danger to the whole organism, easing of pain, and so forth.4

According to the 1983 Code of Canon Law (CIC) 5 there are three levels of teaching offered by the Pope and the Magisterium (those bishops in union with him). These three levels are found in Canons 752 and 754.
    While all of the documents references above may not have the same authority, they are all to be upheld as official teachings of the Church and must be accepted by the faithful as being authentic teachings.
    [4] Theological Analysis: The issue of sexual reassignment surgery is complex with regard to the issues which surround what would inspire someone to want to undergo such a procedure as well providing them with a diagnosis for treatment. Transsexual surgery coupled with hormonal treatment and psychotherapy are used to treat the disorder transsexualism or gender dysphoria syndrome, "a condition in which there is apparent psychological and social identification with attributes of the opposite sex." 6 The Diagnostic and Statistical Manual of Mental Disorders (DSM IV), published under the auspices of the American Psychiatric Association, lists five symptoms of transsexualism:

(1) a sense of discomfort and inappropriateness about one's anatomical sex; (2) a wish to be rid of one's own genitals and to live as a member of the other sex; (3) the disturbance had been continuous (not limited to periods of stress) for at least two years; (4) the absence of physical intersex or genetic abnormality; (5) and the lack of cause due to another mental disorder, such as schizophrenia 7

    From a theological standpoint, these symptoms can be addressed in terms of the inherent value of the human person. As stated above, the Church has consistently taught that the human person has a basic dignity given to us, not because of anything we have done, but because of the very fact that we are made in the image and likeness of God Himself. Chapter One of the Book of Genesis stresses the point that mankind is the pinnacle of God's creation. It was only to man that God gave dominion over the earth and serve as steward of God's creation. While all of God's creatures were given the grace to "be fruitful and multiply", it is only mankind which has the capacity to share, with their offspring, a knowledge of God and provide the conditions under which said offspring may know, love, and serve God in this life and enjoy Eternal beatitude with his or her creator. Only mankind has the ability to actually enter into relationship with another for the purpose of the two becoming one flesh and bringing forth offspring. All animals have the capacity of reproduction; however, no other creature has the capacity to enter into a relationship which has both a unitive and procreative dimension. All other creatures "come together" for the sole purpose of producing offspring. A man and a woman come together both to bring forth offspring as well as support and sustain one another and thereby become a source of sanctification for the other partner.
      A transsexual will never be able to enter validly into a valid sacramental marriage. A man who undergoes sexual reassignment surgery will never really be a woman. He will remain a man, except with a mutilated body and profound psychological issues. Both the unitive and procreative dimensions of marriage are ordered to love. The marital relationship is lived in imitation of the loving communion of the Three Persons of the Holy Trinity, in Whose image both the husband and wife were created. A transsexual will never be able to consummate the marriage in the fullest expression of love of husband and wife, and never will there be a real openness to life and the creation of children. Another issue which is highly problematic is the willful mutilation of healthy and functioning sexual organs in order to undergo this surgery. While it is true that the Church teaches that man is an "embodied spirit" the fact remains that our body should not be disregarded in favor of the spirit. Christian anthropology teaches us that our bodily nature is extremely important since it is in the body which we have received that we give glory to God. At one level, it is actually a lack of charity to attempt to convince or encourage someone to undergo such a surgery because even though a man might be able to develop breasts as a result of hormonal treatments, the fact is that he will always remain a man.  He has a distinctively non-female bodily frame, facial features, and hands. The publicly promoted goal of SRS is to transform a person of one sex into the other sex.  It is physiologically impossible to change a person’s sex, since the sex of each individual is encoded in the genes—XX if female, XY if male.  Surgery can only create the appearance of the other sex.8 While this may not be as noticeable early on after the surgery, as the patient ages those distinctively male character traits will become more and
more pronounced. This can easily lead to all sorts of additional psychological trauma due to the potential lack of social acceptance. This was particularly true to his case. After undergoing two years of psychological counseling, he finally underwent the surgery and
returned to work a few weeks afterward. Northeastern Tennessee is a rather conservative, largely fundamentalist Christian part of the country. When he presented himself to his clients as a woman and was not very well received and, in fact, one by one his clients fired him as their auditor.
    Another issue was how he would be received by women who are aware of his sexual reassignment surgery.  Many women regard the transsexual males’ description of what it means to be a woman—weak and dependent, wanting on to be cared for by a man, addicted to gossip and clothes—as insulting. Dr. Paul McHugh of Johns Hopkins University reports on his impression of men who have undergone SRS:

                  Those I met after surgery would tell me that the surgery and hormone
                   treatments that had made them “women” had also made them happy
        and contented.  None of these encounters were persuasive, however.  The
        post-surgical subjects struck me as caricatures of women.  They wore high
        heels, copious makeup, and flamboyant clothing; they spoke about how
        they found themselves able to give vent to their natural inclinations for
        peace, domesticity, and gentleness—but their large hands, prominent
        Adam’s apples, and thick facial features were incongruous (and would
         become more so as they aged).  Women psychologists who I sent to talk
         with them would intuitively see through the disguise and the exaggerated
         postures. “Gals know gals”, said one to me, “and that’s a guy”. 9

    Apparently this stress was too much to bear for him.  In late October 2007, I received a phone call from the person who first introduced me to him, informing me of the fact that he had committed suicide. What a tragic end to a human life.
   [5] Pastoral Response: The theological concept, incarnation, is fitting to his struggle. According to the Dictionary of Pastoral Care and Counseling (DPCC), incarnation pastoral care is understood in two senses: first, human existence as embodied or incarnated and second, as the doctrine of the Incarnation, that is the mystery of the Second Person of the Trinity's becoming human, Jesus Christ being both fully human and fully divine. 10 The fact that human existence is embodied is primary datum. Humans simply do not exist in a body, but are a body. The idea of bodiliness, as a theological datum, implies that body as a sign of all that a person is. 11 It is in and through our bodies that we experience God's loving self-communication to us. As embodied spirits we primarily experience God's relationship to the world through symbols, nature, and sacraments rather than through doctrinal decrees about creation. God's self-communication is not merely intellectual speculation, but the result of the salvific presence of God in the created world. 12
    Pastoral care involves personal relationships of incarnate beings who are oriented toward God and capable of transcendence because of the paradigm of Jesus' incarnation. 13 A person's experience of alienation, pain, grief, joy, loneliness, fear, death, ecstasy, and fulfillment are not alien to Jesus.14 Jesus was truly like us in all things, except sin.
   How does this relate to his experience? His feelings of shame, inadequacy, and loneliness are all experiences of what could be described as "disincarnation". He does not need to give mere intellectual assent to the belief that God became man and that in doing so He came to save us. Instead, he needs to experience this reality, in his own life. One way that this could be accomplished is by entering into a loving and caring community environment which manifests God's love for us. It is entirely possible that he might resist being receptive to God's love incarnated through me or others due to the fact that this might generally be outside of his experience. His lack of family support could easily be seen as an example of why he might have difficulties with receptivity. A loving relationship involves trust and given his family experience, he might have difficulty trusting others as well.
    As a Christian pastoral care provider and a priest, my effort is to bring the Good News of Jesus to others. One definition of pastoral care is, "The art of communicating the inner meaning of the Gospel to persons at the point of their need." 15 Charles Gerkin expanded the emphasis on incarnational theology beyond the pastoral relationship itself toward recognition of the incarnate presence of God in events and relationships in all human life. 16 Assisting him in feeling that he is loved by God, not because of anything that he has done but simply because he exists, will enable him to move from a sense of guilt and loneliness to one of acceptance and belonging. Incarnating God's love to him does not mean that I condone the choice which he made. In fact, I would have suggested that he consider not having the surgery. However, he is still precious in God's eyes and needs to know that God still loves him even after making, what the Church would consider a wrong decision.
    Jesus' entry into human history did not take place because of our personal worthiness. There is nothing that we can possibly do to earn God's love, compassion, and fidelity.
These are freely bestowed gifts which are made manifest in the lives of believers through the two-fold expression of love of God and love of neighbor. As Christians, we are told to love God with our whole heart, mind, soul, and strength and our neighbor as ourselves. This presupposes that one actually loves him or herself. His decision to mutilate his body would certainly appear to be a characteristic of self-loathing.  The fourth edition of the Diagnostic and Statistical Manual (DSM IV) of the American Psychiatric Association does not list transsexualism as disorder.  This fact does not have a major bearing on how one is dealt with in regard to pastoral care. 
   The pastoral function that appears to fit his dilemma and the theological concept of incarnation is "sustaining". According to William Clebsh and Charles Jeckle, sustaining pastoral care function consists in helping a hurting person to endure and to transcend a circumstance in which restoration to his former condition or recuperation from her malady is either impossible or so remote as to seem improbable. 17 His experiencing of God's self-communication of love in his own life may help him to accept his condition and begin to turn to God and others for assistance and guidance as he realizes that God truly does love him and that one of the ways that love is expressed is through the care and support she receives from those around him. I use the word "may" when speaking about his willingness to accept his condition because such a willingness assumes that he will not simply live in a state of denial.

    The idea of establishing a relationship with God may also entail certain challenges for him. Since it is in the family setting that one initially comes to an understanding of who God is, his lack of family support could easily make him leery of trusting God. It is also possible that he might blame God for feeling like he was a woman "trapped in a man's body". These are the types of issues that would be addressed over a period of time. Experiencing God's love will assist him in beginning the process which will enable him to move beyond what happened in his life and hopefully engage in new relationships with the foundational knowledge that he is loved by God for who he is.
      I see my role in this situation is interpretive guide. Charles Gerkin describes this role as follows, "As interpretive guide of the community of Christians, the pastor is thus called on not only to nurture the process by which the community cares for its members, but also to nurture within the members of the community an awareness of the needs of all people of the world.” 18 My responsibility as an interpretive guide is to both help my parishioners to be a loving and caring community for our members, but also inspire them to reach out to those outside of the community and thereby bring God's self-communication of love to others who are not now part of the group. Part of my priestly identity as an interpretive guide involves my serving as a Compassionate Presence for all those I minister to.
     It is extremely important that pastoral care provider be able to empathically listen to those who come to him for counseling. Listening is an art which can be developed over time, provided that the counselor is truly interested in learning how to listen. Each human life has a story and it is essential that a pastoral care provider listen to the person's story in order to enter into their worldview. When listening to another person there is always the possibility that this other person might have a worldview or personal philosophy which differs greatly from our own. This may become a source of anxiety for the care provider; however, it is essential that he acknowledge his anxiety and move beyond it in order to be of benefit to the patient. All of these dimensions must work together in order for someone to be an effective pastoral care provider.

End Notes
1 Declaration on Certain Questions Concerning Sexual Ethics (Persona Humana) #3. Available in the Enchiridion on the Family, Pontifical Council for the Family, p. 522
2 "Truth and Meaning of Human Sexuality", #8. Available in the Enchiridion on the Family, Pontifical Council for the Family, p. 679
3 Bohr, David A. Catholic Moral Tradition (Second Edition), IN: Our Sunday Visitor, 1998, p. 74
4 O'Rourke, Kevin D. Medical Ethics: Sources of Catholic Teachings (Third Edition), Washington, DC: Georgetown University Press, 1999, p.415
5 Code of Canon Law (New English Translation), Washington, DC: Canon Law Society of America, 1999, pp. 246-247
6 Meyer, James "Psychiatric Consideration in the Sexual Reassignment of Non-Intersex Individuals, Clinics in Plastic Surgery, 1974, p. 48-53
7 Diagnostic and Statistical Manual of Mental Disorders (DSM IV)
8 Fitzgibbons, Richard “The Psychopathology of “Sex Reassignment Surgery” National Catholic Bioethics Quarterly (Spring 2009), p. 118
9 McHugh, Paul R. “Surgical Sex”, First Things 147 (Nov. 2004), p. 34
10Hunter, Rodney (ed.) Dictionary of Pastoral Care and Counseling, Nashville: Abingdon Press, 1990 p. 573
11 Hunter, p. 573
12 Hunter, p. 574
13 Hunter, p. 574
14 Hunter, p. 574
 15 Hunter, p. 574
16 Hunter, p. 573
17 Clebsh, William and Jeckle, Charles R. Pastoral Care in Historical Perspective, p. 9
18 Gerkin, Charles V. An Introduction to Pastoral Care, Nashville: Abingdon Press, 1997, p.127.


Bohr, David A. Catholic Moral Tradition (Second Edition),(1998) IN: Our Sunday Visitor, p. 74

Catechism of the Catholic Church, (CCC) (1998) NY: Catholic Book Publishing Co., #1700, #1706

Clebsh, William and Jeckle, Charles R. (1967)  Pastoral Care in Historical Perspective, p. 9

 Code of Canon Law (New English Translation),(1999) Washington, DC: Canon Law Society of America, pp. 246-247

Declaration on Certain Questions Concerning Sexual Ethics (Persona Humana), #3. Available in the Enchiridion on the Family, Pontifical Council for the Family, p. 522
Diagnostic and Statistical Manual of Mental Disorders (1994) (DSM IV)

Gerkin, Charles V. An Introduction to Pastoral Care, (1997) Nashville: Abingdon Press, p.127.

Hunter, Rodney (ed.) Dictionary of Pastoral Care and Counseling, (1990) Nashville: Abingdon Press, p. 573-574

The Instruction on Respect for Human Life in Its Origins and on the Dignity of Procreation (Donum Vitae). Issued by the Sacred Congregation for the Doctrine of the Faith and available in the Enchiridion on the Family, Pontifical Council for the Family, p. 545

McHugh, Paul R. “Surgical Sex”, First Things 147 (Nov. 2004), p. 34

Meyer, James "Psychiatric Consideration in the Sexual Reassignment of Non-Intersex Individuals”, (1974) Clinics in Plastic Surgery, p. 48-53

O'Rourke, Kevin D. Medical Ethics: Sources of Catholic Teachings (Third Edition), (1999) Washington, DC: Georgetown University Press, p.415

Pope Benedict XVI, Encyclical Letter "God is Love" (Deus Caritas Est), (2006) Washington, DC: USCCB, p. 12.

"Truth and Meaning of Human Sexuality",#8. Available in the Enchiridion on the Family, Pontifical Council for the Family, p. 679

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