Hypoethical case study on how to support your child who comes out as transgender using Natural Law theory

“We must not cease from exploration and the end of all our exploring will be to arrive where we began and to know the place for the first time.” — TS Elliot

Quite literally, the term philosophy means love of wisdom. In a broad sense, philosophy is an activity people undertake when they seek to understand fundamental truths about themselves, the world in which they live, and their relationships to the world and to each other. Philosophy is traditionally divided into four major areas of study:
1. Metaphysics: What is truth?
2. Epistemology: How do we know what we know?
3. Ethics: Is morality objective or subjective?
4. Logic: What constitutes “good” or “bad” reasoning?

I recently submitted this hypothetical ethical case study to my university — my final philosophy assessment for the year. Feedback from my assessor are in italics and brackets:

Ethical dilemma description

I am a pro-life Catholic parent based in Melbourne, Victoria, and am in a relationship with a pro-choice non-Catholic. We both parent a child named John, who is a shy 14 years old, and was born a boy and has shown signs of undergoing natal puberty. Consequently, we raised him as a boy, and we noticed over the years that he does not particularly present as a masculine boy. We did not read into this too much, and let him be. However, he recently started to dress and groom more femininely, become more withdrawn, is increasingly underperforming academically at school, and has now provided us with a ‘coming out’ letter he has written.

John has come out as transgender, and indicated that he has been silently suffering from gender dysphoria for years. He asked that:

1. He be referred to using female pronouns.
2. Her first name to be legally changed to Jane, her preferred name, and the sex listed on her birth certificate to be changed from male to female.
3. She start seeing a range of healthcare professionals to help her medically transition from male to female. This includes access to puberty blockers to halt her male puberty, female hormone therapy, and surgeries that fall under the male-to-female sex reassignment surgery umbrella.

Most alarmingly, she made clear in the conclusion of her letter that if she cannot transition genders, she will likely attempt suicide, since she has been experiencing suicidal ideation in recent times.

My partner responded that as parents, we should fully support Jane’s requests, including avoiding healthcare professionals who would not be supportive of Jane’s request to medically transition. As such, I find this situation to be an overwhelming dilemma for me to grapple with, because Jane’s letter and suicidal ideation, and my partner’s stance, flies in the face of my understanding of Christian anthropology and current Catholic Church teaching on transgender issues.

The Australian Institute of Family Studies (AIFS) defines gender as a socially constructed category that is assigned to someone based on how their biological sex appears at birth.[1] For example, because Jane’s sex appeared male at birth, this is why I raised her as a boy, in the hope that I will see her grow up to be a man. This gender is considered both male and binary — binary because it is the direct opposite to female.

AIFS defines gender identity as an inner self-sense of one’s gender, and sex as someone’s male or female biology consisting of anatomical, chromosomal and hormonal characteristics. However, according to the post-synodal apostolic exhortation Amoris Laetitia, gender is the socio-cultural role of sex, that is, sex and gender are distinguishable from each other but not separate.[2]

Unsurprisingly, AIFS defines ‘transgender’ and ‘trans’ as someone’s internal gender identity incongruent with their sex assigned at birth. However, the Congregation for Catholic Education’s Male and Female He Created Them defines transgenderism as the gender concept dependent on the human person’s subjective mindset, where gender is a choice not necessarily corresponding to their sex, and therefore other’s perception of this.[3]

I do not believe, however, the Catholic Church has an official and direct position on gender dysphoria, which, in Jane’s case, is defined by the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as a marked incongruence between her experienced and expressed gender, and her assigned sex at birth, as manifested by at least two of six criteria listed in DSM-5, associated with clinically significant distress or impairment in functioning in life.[4]

(But isn’t this the fundamental issue? If there’s radical disagreement on the definitions?)

I am also an active and prominent member of my local Parish, and her Catholic high school is part of the same Parish. So even if I was supportive of Jane, and concede that a Catholic position on gender dysphoria does not have to be similar to the Catholic position on transgenderism, news of me taking a supportive position would cause scandal, which I wish to avoid, as she also attends Mass at the same Parish with me. I feel torn, and now turn to my Natural Law study notes (taken during my postgraduate studies at the University of Notre Dame Australia) for further Catholic guidance.

Identification of the basic goods at stake in the ethical dilemma

A good is an action that accords with nature, that is, the act potentially fulfils, or moves towards, the telos that is achievable. This gives rise to basic goods, including the substantive goods of human life (itself — maintenance, transmission, health and safety), knowledge, beauty, and work/play. There are also, reflective basic goods including harmonious relations (community, friendship and justice), psychological well-being, conscience and religion. These are arguably basic goods because they express a desire that is universally human. All of these goods are at stake in the ethical dilemma.

Why is the case study a dilemma?

This case study is a dilemma because there are conflicting goods and therefore, potential evils at stake, as follows:

Relationship with my partner: it is apparent that there is conflicting knowledge between my partner and I. As I am a pro-life Catholic and my partner is not, this means that our consciences can conflict, and we both have different views on religion. This would strain our friendship to various degrees, especially if we have different views on how to parent Jane. For example, my partner’s pro-choice views would include supporting Jane’s requests without question, otherwise known as gender-affirming healthcare.

Jane’s identity as transgender, and her requests that would help her live out this identity: her requests would close herself off from being able to transmit human life, and her medical transition may affect her health and safety, due to the side-effects one can expect of medicine, and potentially being the target of criticism, or worse. How would she know for sure that she is trans, and that being trans is a reality? To my knowledge, she, like any human person, is made in the image and likeness of God, and so it would seem that by pursuing transition, she is showing a lack of appreciation for the beauty of her male biology.

Jane’s suicidal ideation: it appears that her gender dysphoria, which is driving her transgender requests, is increasing her risk of attempting suicide, successful or otherwise. This potential evil at stake is not conducive with the substantive goods of human life and therefore work/play, or the reflective good of psychological well-being.

My desire to avoid scandal: even if medical transition is what will protect Jane’s health, safety and psychological well-being, and that her transgenderness is a reality somehow, the implementation of her requests may not be conducive to harmonious relations, due to how controversial it will come across as. She could lose friends over this, and furthermore, she and I are members of our local Parish, so if I supported her requests, our community, including her high school, would not approve on the basis of both conscience and religion. Her requests will likely curtail both of our access to the good of work/play.

Application of the first principle of practical reason to unpack courses of action (COAs) that could be chosen in the case study: analysis of the practical implications

The first principle of practical reason states that good is to be done and pursued, and evil is to be avoided.[5] Several COAs are available to me for how I should respond to Jane’s ‘coming out’ letter, as follows:

COA 1: do not support any of Jane’s requests. In doing so, I would be upholding the good of my conscience, and the good of my religion and the associated teachings on the matter at hand. Therefore harmonious relations would be maintained at my Parish and at her high school.

Jane has indicated that she will likely attempt suicide in response to COA 1, due to growing suicidal ideation that she has been experiencing. Allowing for the risk of suicide to grow would not be pro-life — indeed, it would not constitute the pursuit of the goods of life and psychological well-being. Even if she would not attempt suicide under COA 1, her increasing academic underperformance and general withdrawal suggests that this COA would further deny her access to the good of work/play.

In general, COA 1 would risk straining my friendship with my partner to the point of irreconcilable differences. To manage this strain, I could attempt to seek healthcare professionals who would be supportive of Jane to consider an alternative pathway in life, however it is unlikely that I will find professionals who would be supportive of psychotherapy that aligns with COA 1, since there is limited evidence to suggest the efficacy of gender-non-affirming healthcare.[6] Specifically, the absence of group studies justifying this approach challenges the perceived good of Catholic knowledge on this subject.

It is also worth noting that in Victoria, there could be legal consequences for pursuing COA 1. Under the Change or Suppression (Conversion) Practices Prohibition Act 2021 (VIC) (“the Act”), it appears that healthcare professionals, my Parish stakeholders, and I, could be prosecuted for discouraging Jane from transitioning genders.[7]

COA 2: support all of Jane’s requests. In doing so, my conscience would struggle to come to terms with her incoming gender transition, and therefore I would question whether I am committed to Catholic social teaching or not. To make matters worse, my Parish and her high school will, at best, heavily scrutinise COA 1, and at worse, ostracise us to the point that we would need to consider changing community membership.

It may appear that under COA 2, the risk of Jane attempting suicide would reduce, and therefore would constitute the pursuit of the goods of life and psychological well-being. This will hopefully allow her to improve her academic performance at school, but that may not necessarily be the case if she would potentially be under the constant threat of ostracisation.

Therefore, such a threat may not reverse her general withdrawal because it would still deny her access to the good of work/play. If this is the cause, then new psychological well-being issues will arise. Otherwise, COA 2 would not lead to further straining of my friendship with my partner.

COA 3: cautiously support Jane’s requests. If I have not already, I would arrange for her to consult a counsellor/psychologist immediately about managing her risk of attempting suicide, and who could refer her onto a psychiatrist who could assess Jane’s gender dysphoria.

The Act would obliged the psychiatrist to conduct a clinically appropriate assessment of Jane’s transgender experience, and it is likely that she will be diagnosed with gender dysphoria in accordance with DSM-5. This assessment would include comprehensive exploration of early developmental history, history of gender development and expression, history of trauma or abuse, emotional functioning, intellectual and educational functioning, peer and other social relationships, family functioning as well as family support.[8]

Therefore, especially if the professional opinion is that medical transition will likely lead to a direct decrease in the risk of attempting suicide, it is likely that she will be referred to a paediatrist/endocrinologist who will prescribe her puberty blockers to halt her male puberty, then place her on female hormone therapy when professionally deemed appropriate.[9] This is the gender-affirming healthcare pathway.

Of note, surgeries that fall under the sex reassignment surgery umbrella cannot be conducted until Jane is 18 years of age, which is beyond the control of stakeholders involved.[10] In any case, during the course of COA 3, a legal name change to Jane would make sense due to her new gender presentation, and law-permitting, so would changing the sex listed on her birth certificate.

Whilst COA 3 is based on compliance with positive law, it would not completely prevent me from applying the first principle of practical reason, and be guided by my conscience. As far as I know, the Act would not prevent me from continuing to have respectful conversations, with my partner and Jane, about the reasons why Christian anthropology is good, including the transmission of human life, and the beauty entailed with that. I would have respectful conversations about the side-effects that she may experience as part of her medical transition, including being closed off to being able to transmit human life.

The aim of such conversations is not to pressure her to change her mind about transition, rather, the aim is to help her to discern her transgender experience. That is, providing her with an intellectual toolkit to help her pursue the good of knowledge, and therefore truth, whilst avoiding the evil that would drive her to attempt suicide. This is especially so for Jane, given that her brain is most likely not sufficiently developed, since higher brain function, like planning, reasoning, judgement and impulse control, would only fully develop by her 20s.[11]

As much as I love my Parish life as it is, in order to maintain harmonious relations under COA 3, I would move to another Parish in Melbourne during the early days of Jane’s social and medical transition, and I would enrol Jane into a new non-Catholic high school in order to protect her privacy and safety as much as I can. A new community for the both of us would provide us with new friendship and work/play opportunities, and a new opportunity for Jane to complement her non-Catholic schooling with Catholic education opportunities outside of school hours.

Upon review of the above COAs, and after much consideration in response to the hypoethical case study thus far, my COA of choice is COA 3: cautiously support Jane’s requests.

Evaluation of COA of choice in the natural law theory context

Eternal law is the Divine Wisdom of God overseeing the common good governing everything, and natural law is the human person’s participation in eternal law.[12] The relevant natural law-related principles on the question of gender transition are the principles of double-effect and totality.

Double-effect would seem to not be applicable because gender transition’s immediate end is not good, since, for example, it would close Jane off from being open to transmitting human life.[13] However, whilst Jane’s body-soul composite is not ontologically disintegrating, Pope Pius XII’s principle of totality would still be applicable, where parts of the body are sacrificed for the sake of psychological well-being and self-preservation of life. In applying the principle, three criteria must be met:

1. Non-gender transition of the body will continue to render gender dysphoria unalleviated
2. The gender dysphoria associated with the body parts in question is unavoidable, and can only be alleviated by well-assured and efficacious medical transition; and
3. It is reasonable to expect that a net positive effect will arise from the transition plan specified.[14]

Coupled with positive law obligations which have some alignment with the principle of totality, COA 3 is the COA of choice for following the first principle of practical reason. A positive law is an interpretation of natural law in a particular context different to others. Regardless of the merits of the Act, which is hotly contested,[15] one of the reasons why positive law is required, is that the assumption that natural law is already in existence more or less does not itself provide sufficient solutions to the co-ordination problems of communal life.[16]

The hypoethical case study exemplifies this reason, moreso due to Jane’s history of suicidal ideation and the risk of her attempting suicide. Factoring this in, the principle of double-effect would be applicable because the immediate end of gender transition in order to reduce the risk of Jane attempting suicide is morally neutral. Indeed, the existence of self-destructive human behaviours challenges the traditional natural law claim that the human person naturally self-preserves.[17]

According to Evangelium Vitae, although suicide rejects the eternal law on life and death, it acknowledged that psychological conditioning may induce a human person to act radically and in contradiction to the basic good of life, thus lessening subjective responsibility.[18] COA 3 would avoid leaving Jane in such a vulnerable situation.

(A very good paper, Dana — a lot of research, some good insights and some interesting points. To note: much of the case study relies on arguments about outcomes, or empirical claims about side-effects, which are then considered ‘ends’ (or evils to be avoided) in the actions, thus confusing an end with an outcome/side-effect.)

Bibliography

American Psychiatric Association. “What Is Gender Dysphoria?” Accessed October 03, 2021. https://www.psychiatry.org/patients-families/gender-dysphoria/what-is-gender-dysphoria.

Aquinas, Thomas. Summa theologica. Translated by Fathers of the English Dominican Province. New York: Benziger Brothers, 1911–1925.

Australian Institute of Family Studies. “LGBTIQA+ communities glossary of common terms: CFCA Resource Sheet — November 2019.” Accessed October 03, 2021. https://aifs.gov.au/cfca/publications/lgbtiq-communities.

Australian Professional Association for Trans Health. “AusPATH: Public Statement on Gender Affirming Healthcare, including for Trans Youth.” Accessed July 09, 2021. https://auspath.org/gender-affirming-healthcare/.

Congregation for Catholic Education (for Educational Institutions). Male and Female He Created Them: Towards a Path of Dialogue on the Question of Gender Theory in Education. Document. Vatican website. June 10, 2019. http://www.educatio.va/content/dam/cec/Documenti/19_0997_INGLESE.pdf.

Finnis, John. Natural Law and Natural Rights. Oxford: Oxford University Press, 1980.

Francis. Amoris Laetitia. Post-Synodal Apostolic Exhortation. Vatican website. March 19, 2016. https://www.vatican.va/content/dam/francesco/pdf/apost_exhortations/documents/papa-francesco_esortazione-ap_20160319_amoris-laetitia_en.pdf.

Gremmels, Becket. “Sex Reassignment Surgery and the Catholic Moral Tradition: Insight from Pope Pius XII on the Principle of Totality.” Health Care Ethics USA 24, no. 1 (2016).

Bedford, Elliott Louis and Eberl, Jason T. “Is the Soul Sexed? Anthropology, Transgenderism, and Disorders of Sex Development.” Health Care Ethics USA 24, no. 3 (2016).

Health Legal. “Victoria Bans Change or Suppression Practices.” healthlegal.com.au, April 12, 2021. https://healthlegal.com.au/current-news/victoria-bans-change-suppression-practices/.

healthdirect. “Gender confirmation surgery.” healthdirect.gov.au, accessed November 20, 2021. https://www.healthdirect.gov.au/gender-confirmation-surgery.

John Paul II. Evangelium vitae. Encyclical Letter. Vatican website. March 25, 1995. https://www.vatican.va/content/john-paul-ii/en/encyclicals/documents/hf_jp-ii_enc_25031995_evangelium-vitae.html.

Rodrigues, Marilyn. “Victorian lawmakers ignore warnings on ‘conversion’ ban.” catholicweekly.com.au, February 10, 2021. https://www.catholicweekly.com.au/victorian-lawmakers-ignore-warnings-on-conversion-ban/.

Stanford Encyclopedia of Philosophy, sv “Suicide.” plato.stanford.edu. Metaphysics Research Lab. 2021, November 09. https://plato.stanford.edu/entries/suicide/.

Telfer, Michelle M, Tollit, Michelle A, Pace, Carmen C, and Pang, Ken C. “Australian standards of care and treatment guidelines for transgender and gender diverse children and adolescents.” Medical Journal of Australia 209, no. 3 (2018).

Trevitt, Sophie and Browne, Bill. “Raising the age of criminal responsibility.” Discussion paper, The Australia Institute, 2020. https://australiainstitute.org.au/wp-content/uploads/2020/12/P952-Raising-the-age-of-criminal-responsibility-Web.pdf.

Footnotes

[1] “LGBTIQA+ communities glossary of common terms: CFCA Resource Sheet — November 2019,” Australian Institute of Family Studies, accessed October 03, 2021, https://aifs.gov.au/cfca/publications/lgbtiq-communities.

[2] Francis, Amoris Laetitia, post-synodal apostolic exhortation, Vatican website, March 19, 2016, https://www.vatican.va/content/dam/francesco/pdf/apost_exhortations/documents/papa-francesco_esortazione-ap_20160319_amoris-laetitia_en.pdf.

[3] Congregation for Catholic Education, Male and Female He Created Them: Towards a Path of Dialogue on the Question of Gender Theory in Education, document, Vatican website, June 10, 2019, http://www.educatio.va/content/dam/cec/Documenti/19_0997_INGLESE.pdf.

[4] “What Is Gender Dysphoria?” American Psychiatric Association, accessed October 03, 2021, https://www.psychiatry.org/patients-families/gender-dysphoria/what-is-gender-dysphoria.

[5] Thomas Aquinas, Summa theologica, trans. Fathers of the English Dominican Province (New York: Benziger Brothers, 1911–1925), Ia IIae, q. 94, a. 2.

[6] “AusPATH: Public Statement on Gender Affirming Healthcare, including for Trans Youth,” Australian Professional Association for Trans Health, accessed July 09, 2021, https://auspath.org/gender-affirming-healthcare/.

[7] Health Legal, “Victoria Bans Change or Suppression Practices,” healthlegal.com.au, accessed April 12, 2021, https://healthlegal.com.au/current-news/victoria-bans-change-suppression-practices/.

[8] Australian Professional Association for Trans Health, “AusPATH: Public Statement on Gender Affirming Healthcare, including for Trans Youth.”

[9] Michelle M Telfer, Michelle A Tollit, Carmen C Pace and Ken C Pang, “Australian standards of care and treatment guidelines for transgender and gender diverse children and adolescents,” Medical Journal of Australia 209, no. 3 (2018).

[10] healthdirect, “Gender confirmation surgery,” healthdirect.gov.au, accessed November 20, 2021, https://www.healthdirect.gov.au/gender-confirmation-surgery.

[11] Sophie Trevitt and Bill Browne, “Raising the age of criminal responsibility” (Discussion paper, The Australia Institute, 2020), 11, https://australiainstitute.org.au/wp-content/uploads/2020/12/P952-Raising-the-age-of-criminal-responsibility-Web.pdf.

[12] Aquinas, Summa theologica, Ia IIae, q. 91, arts. 2.

[13] Elliott Louis Bedford and Jason T Eberl, “Is the Soul Sexed? Anthropology, Transgenderism, and Disorders of Sex Development,” Health Care Ethics USA 24, no. 3 (2016).

[14] Becket Gremmels, “Sex Reassignment Surgery and the Catholic Moral Tradition: Insight from Pope Pius XII on the Principle of Totality,” Health Care Ethics USA 24, no. 1 (2016).

[15] Marilyn Rodrigues, “Victorian lawmakers ignore warnings on ‘conversion’ ban,” catholicweekly.com.au, February 10, 2021, https://www.catholicweekly.com.au/victorian-lawmakers-ignore-warnings-on-conversion-ban/.

[16] John Finnis, Natural Law and Natural Rights (Oxford: Oxford University Press, 1980), 28.

[17] Stanford Encyclopedia of Philosophy, sv “Suicide,” Metaphysics Research Lab, November 09, 2021, https://plato.stanford.edu/entries/suicide/.

[18] John Paul II, Evangelium vitae, encyclical letter, Vatican website, March 25, 1995, https://www.vatican.va/content/john-paul-ii/en/encyclicals/documents/hf_jp-ii_enc_25031995_evangelium-vitae.html.