In the United States, the message that many transgender teenagers are receiving with radiating clarity from Catholic institutions, particularly Catholic schools, is that there is no room at the table for them—or, alternatively, if there is room, that the space comes with a number of conditions that may amount to practically an absence of space anyway. For example, in the policy currently operative in my home diocese of Green Bay, WI, transgender teenagers who choose to socially transition—that is, teenagers who either have chosen to identify themselves using names or pronouns that differ from those that they were initially given at birth or have chosen to use facilities (like locker rooms and restrooms) that correspond to their chosen identities—cannot be addressed using those names or pronouns, nor can they use those locker rooms or restrooms. Instead, per the policy, the diocese “supports and encourages” psychological counseling, so long as the medical professionals providing such care “hold a correct Christian anthropology of the human person and who understand and adhere to Catholic teaching.”[1] That Catholic teaching, as many of us may know, is that any form of gender transition is problematic because it constitutes a misuse of our freedom because it fails to respect God’s design for humankind in which each and every one of us is either a male or a female, destinated to become a man or a woman, respectively.
Policies like these are limited to particular dioceses, but it is important to recognize that these policies are not scarce. They can be found in Lafayette, LA; Arlington, VA; Indianapolis, IN; Milwaukee, WI; St. Louis, MO; Hartford, CT; and Orange, CA; and New York, NY, among other places. By one count, though they vary in severity of language and length, there are over 30 of these sorts of documents just in the United States alone. And this is to say nothing about the world that lies beyond the ecclesial context in the US political context more broadly. According to one estimate, there have been 556 anti-trans bills considered in 49 states in this year alone—laws that, in some areas, would make providing gender-affirming care a felony crime; laws that forbid addressing transgender persons by their chosen pronouns; laws that consider providing any medical gender-affirming care a form of child abuse; and laws that ban books that “promote gender fluidity or gender pronouns.” Twenty-seven of these laws are being proposed at the national level.[2] For its part, the national body known as United States Conference of Catholic Bishops, in a recently issued doctrinal note titled “On Moral Limits to Technological Manipulation of the Body,” maintain that all forms of medical gender-affirming care constitute bodily mutilation. They write,
Catholic health care services must not perform interventions, whether surgical or chemical, that aim to transform the sexual characteristics of a human body into those of the opposite sex or take part in the development of such procedures. They must employ all appropriate resources to mitigate the suffering of those who struggle with gender incongruence, but the means used must respect the fundamental order of the human body.[3]
The various sorts of medical and ethical questions raised by the prospect of adolescent transgender patient care can easily seem overwhelming, and the stakes of offering responses to such questions are raised especially higher as we watch the lives of transgender youth and adults used as wedge issues in the American political culture wars. In response, I want to sketch the contours of an ethical proposal that imagines the specific project of adolescent transgender patient care through the theological motif of co-creation—where the primary partners in this co-creative project are the transgender patient and God, and where the secondary partners are healthcare providers, spiritual advisors, and other caregivers, such as parents. I offer this in the spirit of one who does not explicitly identify as transgender or genderqueer, but who hopes to be seen as someone who acts in solidarity with those who do experience this reality.
The first principle I’d like to offer in this sketch maintains that one should respect the primacy of the relationship between the transgender adolescent and God as one of calling and discipleship. Importantly, such a principle is capable of being generalized across all domains of a transgender person’s life, not necessarily only over one’s gender identity, but I believe this strengthens rather than weakens the principle’s effectiveness. After all, we all experience God as embodied beings, and to the extent that God calls any of us, God calls us in and through our bodies. Following transgender theologian Justin Sabia-Tanis, who has encouraged us to think of gender as a “calling,” I, in some of my previous work, have tried to register this calling within the Catholic natural law/virtue ethics tradition as one that moves the person towards achieving the virtue of gender alignment through cultivating the habits that curate one’s gender identity accordingly.[4]
Some crucial observations follow from this. On the one hand, respecting the primacy of the relationship between the transgender adolescent and God means recognizing that the ultimate court of last resort for judging the morality of an action related to gender-affirming care remains with the transgender person whose conscience is in the process of development. But on the other hand—and moderating the potential scope of the former observation—respecting the primacy of this relationship necessarily points the transgender adolescent towards a community of support as they journey towards God, since love of God points us automatically back towards communities where we can love and learn from other people. It is here where a number of secondary but nevertheless essential partners come into focus, including one’s caregivers, one’s healthcare providers, and one’s spiritual advisors who together not only help the transgender adolescent develop their conscience, but more importantly, who authentically and openly accompany the transgender adolescent on their overall journey towards God, which includes achieving the virtue of gender alignment.
The second principle I’d like to advance applies to all of those who are supporting the journey of the transgender adolescent on their journey towards God’s gender calling for their lives—that is, caregivers, healthcare providers, and spiritual advisors. The principle is the following: Choose Life. The principle encourages us all of us to see supporting the transgender adolescent’s journey towards gender alignment as an aspect of the Catholic Church’s overall pro-life witness that honors the dignity of each and every person as created in the image and likeness of God. What actions do this? What we’ve been learning from study after study is that the single best thing that we can do for a transgender adolescent (indeed for any person experiencing gender dysphoria) is to accept them at every point of their gender journey. Indeed, this can be literally lifesaving. One 2020 study published in the Journal of Interpersonal Violence found that 86% of transgender youth experienced suicide ideation, and 56% of transgender youth attempted to take their own lives.[5] Which event was found to be one of the most statistically significant when transgender youth reported a suicide attempt? Emotional neglect by family, which when experienced by a transgender adolescent, made them 2.5x more likely to report a lifetime suicide attempt. What was one of the questions asked in order to determine emotional family neglect: “Did you often or very often feel that no one in your family loved you or thought you were important or special?”
The final principle I’d sketch here is in reference to healthcare providers specifically: it is to provide gender-affirming care in a prudential way. It is important to make clear without any equivocation that the state of scientific research into the transgender adolescent experience is still growing. An important guidepost along the way here is the 8thedition of the Standards of Care—released in 2022—published by the World Professional Association for Transgender Health (WPATH) which affirms that gender-affirming care for adolescents must be conducted in a way that affirms allpotential resolutions of gender dysphoria (so this means that the possibility of a cisgender identity is not ruled out), and that hormonal and surgical gender-affirming care for adolescents must happen in the context of an ongoing relationship that monitors for other potentially complicating mental and physical disorders. [6] The WPATH recommendations are not without controversy, and they do admit the fact that certain hormonal and surgical procedures are not without risks. This is why this care must be prudent, like all forms of treatment that involve risk for the sake of the greater good of the patient.
To close—and in full acknowledgement that there is so much more that can be said—I want to impress upon us once again the urgency of the question of adolescent transgender care. The world, which has already been dangerous for trans people, is becoming more dangerous and more precarious. My hope in sketching these three principles of an ethical approach to affirming adolescent transgender care is that we might be able to lay a path forward for genuine Catholic accompaniment of young trans people, which is the pastoral posture to which Pope Francis calls us.
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[1] Diocese of Green Bay, “Education Policy Manual SY 22-23,” https://docs.google.com/document/d/1Rnq1qw_QwtQ7eM0KyBX4HDfnxeoU-9TFh_5O1GUnK5c/edit#heading=h.26m55dakmi6l, §5045.1 & §5045.2 (pp. 70-71).
[2] Trans Legislation Tracker, “2023 Anti-Trans Bill Tracker,” https://translegislation.com.
[3] USCCB Committee on Doctrine, “Doctrinal Note on the Moral Limits to the Technological Manipulation of the Human Body,” (20 March 2023), https://www.usccb.org/resources/Doctrinal%20Note%202023-03-20.pdf, no. 18.
[4] See my “Born That Way? The Challenge of Trans/Gender Identity for Catholic Theology,” in Sex, Love, and Families: Catholic Perspectives, ed. Jason King and Julie Hanlon Rubio (Collegeville, MN: Liturgical Press, 2020), 91-101.
[5] Ashley Austin, Shelley L. Craig, et al., “Suicidality Among Transgender Youth: Elucidating the Role of Interpersonal Risk Factors,” Journal of Interpersonal Violence 37 no. 5-6 (March 2022):NP2696-NP2718, DOI: https://doi.org/10.1177/0886260520915554.
[6] E. Coleman, A.E. Radix, et al., “Standards of Care for the Health of Transgender and Gender Diverse People, Version 8,” International Journal of Transgender Health 23, sup. 1 (September 2022): S1-S259, DOI: 10.1080/26895269.2022.2100644.