Should a human person, who identifies as transgender, transition genders?

I recently submitted this essay to my university. Feedback from my assessor are in italics and brackets:

Identification of a contemporary moral issue

Support for the human person, who identifies as transgender, to transition genders, is increasingly mainstream.[1] At stake in the debate as to whether they should transition or not is first and foremost, definitions. Without a clear understanding of the definitions, the debate will lead to avoidable misunderstandings that can protract the debate unnecessarily.

But first, some context as to why this is an important debate. Genesis is the first book of the Christian Bible, and this fundamental book is shared by Judaism and Islam.[2] One of the first matters this book clarifies is the role of sex and gender. From the Christian perspective, for the human person to be like God, he or she would embrace the maleness and femaleness He created them with, respectively, as per Genesis 1:27. (Actually, it’s personhood that’s primary as it is personhood that “images” not gender)

Judaism, Christianity and Islam make up more than half of the world’s population.[3] Because of how fundamental Genesis is to these three world religions, if it was to be removed from scriptures, theology becomes severely corrupted. These religions would have also built the societies and cultures of more than half of the world’s population, therefore the redefining of sex and gender to definitions outside the scope of scripture would affect more than half of the world’s population’s understanding of sex and gender. (OK, but for a philosophical paper, best to begin with philosophical sources. These are more points from an historical perspective not philosophical)

The transgender position is an ethical issue because it fundamentally affects what one would understand to be, the dignity of the human person. (This needs definition though, and also you need to link how gender per se then links to dignity) For example, from a Catholic perspective, human persons become like God when they lead the expected virtuous life.[4] If this expectation is the telos, then the full embrace of the natal maleness or femaleness moves the human person towards eudaimonia.[5] Therefore, it seems that the human person will not be happy, and will not be able to live a good life, if they transition genders. (But isn’t it more the case that we embrace our personhood though as male or female? Personhood (child of God ultimately) is the fundamental referent)

Because of how controversial this contemporary issue is, it is important that this essay explores definitions and key concepts. One approach to this is to compare and contrast relevant definitions provided by the Australian Institute of Family Studies (AIFS) and the Catholic Church.

AIFS refers to ‘gender’ as a category that is socially constructed and assigned to someone based on their apparent sex at birth.[6] For example, the male gender refers to man or masculine, and the female gender refers to woman or feminine. This type of contrasting classification refers to the ‘gender binary’, which falls within the scope of this essay. Of note, non-binary gender, which describes a non-conventional gender identity that may be expressed as other than man or woman, does not fall within the scope of this essay due to word limit. ‘Gender identity’ refers to an inner self-sense of one’s gender.

AIFS refers to ‘gender norms’ as gender-defined dress and behaviour expectations. ‘Sex’ refers to someone’s anatomical, chromosomal and hormonal characteristics, classified as either male or female at birth based on apparent anatomy. ‘Intersex’ refers to having such characteristics that differ from conventional understandings of male and female bodies, which is separate from their gender identity. In Amoris Laetitia, Pope Francis contrasted the AIFS definitions by referring to the socio-cultural role of sex, as gender, and reiterated that biological sex and gender can be distinguished from each other but not separated.[7]

AIFS refers to ‘transgender’ and ‘trans’ as someone’s internal gender identity not matching their assigned sex at birth. In terms of transitioning genders, trans people may choose to live their lives with or without modifying their dress, legal status or other non-medical gender presentation (social transition), and with or without medical transition (body modification). However, the Congregation for Catholic Education’s Male and Female He Created Them defines transgenderism as the concept of gender that depends on the subjective mindset of the human person, who can choose a gender not corresponding to their biological sex, and therefore other’s perception of this.[8]

In short, AIFS has taken a Cartesian dualist approach to defining the terms above, whereas the Catholic Church has taken an Aristotelian-Thomistic approach, because sex is inseparably and essentially accidental.[9] (But Descartes wasn’t able to account for how the body and soul interact. Given what you argue here (that what one thinks of their body doesn’t match their biological reality) how would Descartes defend these terms within his framework? He can’t account for a “mismatch.”) Cartesian dualism differentiates the material body from the immaterial soul, and emphasises the soul as the human person’s identity.[10] Therefore, gender identity, part and parcel to the soul, can radically disconnect the body from the soul, due to the mismatching biological sex of the body. (But is it? I think this is a point that needs further clarification in the argument)

However, St Thomas Aquinas recognised that the human person is a body-soul composite, with no dual nature to themself, therefore conscious of their sense and using it to understand the world around them. If soul-driven sensing requires a body, therefore the body-soul composite cannot be broken down.[11] Aquinas was unsurprisingly Aristotelian in interpretation, in positing that the soul drives the body to live, because the soul is the substantial form of the living body.[12]

Therefore, the affirmative (Cartesian dualist) position of this debate is that a human person, who identifies as transgender, should transition genders if he or she desires to. (I’m still not convinced that Descartes would accommodate this move because his theory is too weak on the on body-soul relationship) The negative (Aristotelian-Thomistic) position is that a human person should not transition genders. The middle ground is that a human person, who identifies as transgender due to gender dysphoria, should only transition genders to the extent required to alleviate the dysphoria. (I’m not really clear on what you are arguing here. What would “to the extent” be evaluated against?) The middle ground is known as transmedicalism.[13]

Identification of the key positions and proponents/opponents of these positions in Natural Law

The affirmative position would be inclined towards the definitions of the key concepts provided by AIFS, whereas the negative position would be inclined towards the definitions provided by the Catholic Church. Transmedicalism would be inclined towards both sets of definitions, to what extent proportionally would be on a case-by-case basis in relation to a given gender dysphoria patient and the nature of their diagnosis. (This move in your argument here doesn’t seem very strong: what is the criteria philosophically to evaluate the “proportionality”?)

The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, otherwise known as DSM-5, defines gender dysphoria in adolescents and adults as a marked incongruence between the human person’s experienced and/or expressed gender, and their sex assigned at birth, as manifested by at least two of six criteria.[14] Two examples of the criteria are:

1. A marked incongruence between one’s experienced and/or expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics as part of puberty)

2. A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced and/or expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics).

In addition, the diagnosed gender dysphoria must be associated with clinically significant distress or impairment in social, occupational, or other areas of functioning in life. The criteria for diagnosing gender dysphoria in children does not fall within the scope of this essay due to word limit. (You need some kind of transition paragraph here to tell the reader what you are about to address; it changes focus all of a sudden)

The affirmative position assumes that the human person can reconstruct their human personhood, including sex and gender, and the dignity associated with it, in order to become an authentic-self, an act which takes Cartesian dualism to its logical conclusion. (So how is “reconstruct” compatible with Descartes?) In social talk, this is known as “living your best life”, pursuing individual desires without regard for other than the self. (This is a problematic argument: you have “dignity”, “authentic” and “self” in the same sentence but you are using each of these terms in a way that is not coherent in Descartes’ system) It is a culture of pursing the basic human good of life at the expense of other goods,[15] regardless of whether it is driven by gender dysphoria or not. (Not sure how this follows what you just said)

The negative position assumes Aquinas’ position because it aligns with the Catholic Thought that living out the telos as described in this essay will lead to true freedom. Since the soul is driven by desire that habituates into disposition, when the human person’s disposition synergises with their intellect, the soul can will the body to reason in order to attain a number of basic human goods.[16] (This needs more development)

One of these types of good is marriage between man and woman and bringing up of children.[17] Since God created man and woman in His image and likeness, he therefore expects them to be reproductive (reproduce the good of life) and therefore further their stewardship over the world around them (Genesis 1:28). The reciprocation and complementarity of this love shows respect for the physical body.[18] This process of marriage and natural family forms a building block of society — sociability is the tertiary good here.

Transmedicalism is a balanced approach that assumes that the pathway to self-authenticity should be restrained, that it should not be unbridled, noting the reality of the human person as explained by Aquinas. That is, transgender healthcare provision should be focused on strictly alleviating gender dysphoria, and nothing more. (You haven’t really gone into transmedicalism and made a case for how it is a “balanced approach.” It seems that you are just assuming this within your argument)

In support of the affirmative side, some studies have shown that self-authenticity is associated with psychological and social improvement. For example, higher self-esteem, greater well-being, better romantic relationships and enhanced work performance.[19] Specifically, meta-analyses have cautiously supported the efficacy of trans people medically transitioning genders. For example, one of these meta-analyses conclude that some low-quality evidence suggests that sex reassignment surgery (SRS) will likely improve trans people’s quality of life (QoL).[20] (You’re shifting focus again — from natural law to healthcare to psychology to medicine. In order to really make a philosophical case, one needs to stay with a philosophical line of reasoning otherwise there’s a risk of internal incoherence in your overall argument)

The negative side have quoted a longitudinal study that followed over 300 post-operative trans people in Sweden during the period 1973–2003, and included a comparison group, where for every trans person followed, the researchers included a cisgender person (non-transgender) of same age and biological sex. It concluded that trans people who have had SRS are at considerably higher risk for mortality, suicidal behaviour, and psychiatric morbidity than the general population.[21] (You’ve forsaken the philosophical argument for an argument from psychology but each has different criterion for what constitutes a strong argument)

However, the Swedish finding was not that SRS caused the higher risks, because gender dysphoria is a distressing condition in itself. The researchers of the study have confirmed that gender dysphoria comorbidity is an ongoing concern, pre or post-operative, and that any surgery and medical treatment is not risk-free. Specifically, professional and relational problems post-SRS may continue.[22]

Other negative concerns include that in general, hormone therapy, as part of medical transition to produce/curtail secondary sex characteristics, is associated with health risks such as blood clots, high blood pressure, stroke, cardiac disease, cancer and diabetes.[23] The negative side would therefore conclude that what is needed is psychotherapy for those who identify as transgender, but it appears that the evidence for this conclusion in support of moving towards the telos is also lacking. For example, one gender dysphoria patient has described her experience with psychotherapy as follows:

“Despite my pleas for help, I was under 18 and my parents disapproved of my wish to transition. Counselling and psychotherapy were offered instead, which felt like dancing around the solution. My life prior to transition was incredibly miserable. I was under a lot of pressure to make counselling and psychotherapy work, which only exacerbated my dysphoria and made my sense of worth nosedive. This felt like unbridled psychological abuse; it disrupted my friendships, studies, and social development, not to mention my relationship with my parents.”[24]

In light of the specific shortcomings of the affirmative and negative positions, there appears to be more meta-analyses supportive of transmedicalism. Evidence suggests that trans people have a relatively lower QoL, and whilst there is some evidence to suggest that medical transition overall does improve QoL for these people, further studies of higher quality are required. This includes clearly defining trans populations in future studies, divided by stage of medical transition, and with corresponding control groups, in order to draw more credible conclusions.[25] (But these are arguments from psychological and medical cases)

For hormone therapy specifically, evidence suggests minimal adverse impact on the cognitive function of trans people, but new longitudinal studies with longer follow-up should explore the long-term effects of hormone therapy.[26] For SRS, whilst there is evidence showing improvement in some QoL dimensions, including mental health aspects, further research is required to corroborate this.[27]

Analysis of the arguments in relation to Natural Law Theory

Based on this essay thus far, all of the original Aquinas basic human goods[28] are at stake in this debate. (But as Alasdair MacIntyre argues, we don’t get a coherent philosophical argument when the principles within each theory conflict. What you have presented so far is embedded in many different forms of argumentation, each of which holds different principles that conflict) There are tensions between the good of life (to an extreme degree) as prioritised by the affirmative position, and the goods of marriage and natural family (the good of life is embedded within this good), and sociability, as prioritised by the negative position. But on both sides of these tensions is the good of knowledge at odds with each other, given that this is a highly contentious debate with conflicting knowledge, as demonstrated thus far in this debate. Without the good of knowledge, it would not be clear what are the goods at stake in this debate.

The evils would be the non-pursuit of goods perceived by one side of the debate of the other side, hence the polarisation. This is where transmedicalism capitalises on the good of knowledge that both sides of the debate have on what drives their conflicting goods priorities, in pursuit of the good of practicable reasonableness. (This isn’t a valid philosophical move since you’re arguing as if transmedicalism agrees with what natural law (of both kinds) sees knowledge as. What “good” and “knowledge” mean for each stems out of different underlying principles.)

Transmedicalism recognises that the negative position is prone to take a simplistic view of the good of life, as a good embedded within the good of marriage and natural family. An example of this is the mistaken assumption about the Swedish longitudinal study highlighted in this essay. Therefore, the practicably reasonable response is to restrict the focus of transgender healthcare provision to gender dysphoria alleviation, thereby prudently protecting the good life, and not crossing this boundary at further expense of the good of marriage and natural family. This does not neatly follow the first principle of practical reason,[29] but this is due to the complexities associated with gender dysphoria. (What you’re picking up is a conflict of the principles underlying natural law and transmedicalism: the view of the person and the good for the person are incompatible)

By balancing the competing goods via practicable reasonableness, the gender dysphoria patient can still achieve good sociability post-transition. As inferred by the meta-analyses mentioned in this essay, medical transition can to varying degrees, help the patient blend their social transition and associated gender presentation into society. (How does one evaluate “good” here? Natural law is clear, but I am not sure how the medical evaluates it) The balancing act fosters a social middle ground that tries to contain a Cartesian dualist culture from dominating an Aristotelian-Thomistic reality in thought. (Still not convinced that it is Cartesian)

The balancing act would start with screening gender dysphoria patients considering medical transition for comorbidities. An example of gender dysphoria comorbidity is body dysmorphic disorder (BDD), which the negative position has unfairly drawn an analogy between both conditions.[30] BDD drives a desire for a less than healthy body regardless of sex, whereas gender dysphoria drives a desire for a healthy, and not necessarily perfect, opposite-gender presentation. Gender dysphoria treatment involves alignment blending to bring about dysphoria alleviation, whereas BDD may be more of an ongoing dissatisfaction with particular healthy body parts.[31] (Are you using transgender and gender dysphoria interchangeably?)

Screening for comorbidities as part of the diagnostic process is the application of the principle of double effect to determine a medical transition plan within proportion, thereby creating a good effect that excludes ongoing and cosmetic procedures for indirectly addressing comorbidities. (How so?) Therefore, some types of hormone therapy and SRS are more practicably reasonable than others depending on the patient, but nevertheless the medical transition itself is likely to cause sterilisation, which is a bad effect, and tends to be neutral.[32]

Sterilisation arising from medical transition is regrettable, but this is not a case of consequentialism, since gender dysphoria does not revolve around sterilisation. Nevertheless, the principle of double effect should be considered as part of a more comprehensive bioethical principle: Pope Pius XII’s Principle of Totality.[33] (But what you previously described isn’t the principle of double effect. You can’t prise off the “effect” from the principle driving it which is a metaphysical one and has a very particular view of the person and of the good for the person) The principle of totality can further assist applied transmedicalism discern the treatment plan, particularly SRS. In applying the principle, three criteria must be met in order to justify SRS:

1. The retention of an anatomical sex organ will continue to render gender dysphoria unalleviated

2. The gender dysphoria associated with the organ in question is unavoidable, and can only be alleviated by a well-assured and efficacious SRS on the organ; and

3. It is reasonable to expect that a net positive effect will arise from said SRS.

SRS efficacy is well-assured, especially under prudent medical transition guidelines, which emphasises the imperative for engagement and assessment between the patient and their treating professional, and adherence to this is associated with low rates of regret and detransition.[34] This is a reasonable Natural Law plan of action.[35]

Since a patient will be more gender dysphoric about certain aspects of their body and presentation than other aspects, certain SRS will be more reasonably practicable than others, or may not be required at all for alleviation. Hormone therapy intensity and pace required may vary from patient to patient depending on the nature of the dysphoria requiring alignment blending to alleviate. To deviate from this practicably reasonable approach for a good life dealing with gender dysphoria is to not carefully consider the principles of double effect and totality, perhaps due to an unaddressed comorbidity.

(You have clearly put a lot into this essay, Dana and that’s excellent to see. You have used some very good sources in your bibliography as well. My main comment in regard to your arguments in this essay is that many of them have different underlying principles which conflict with each other and introduce internal incoherence to the overarching case you are trying to make. Take a look at my comments in the essay on this point. Something to watch out for is not taking parts out of other arguments that seem to work for your own because the context from which those parts come are essential to the force of that part.)

Bibliography

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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/.

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Beer, Jennifer. “The Inconvenient Truth about Your “Authentic” Self.” Observations (blog). Scientific American, March 05, 2020. https://blogs.scientificamerican.com/observations/the-inconvenient-truth-about-your-authentic-self/.

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Brugger, E Christian. “Catholic Hospitals and Sex Reassignment Surgery: A Reply to Bayley and Gremmels.” National Catholic Bioethics Quarterly 16 (2016): 587–597.

Catechism of the Catholic Church. 2nd ed. Vatican City: Vatican Press, 1997.

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Dhejne, Cecilia et al. “Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden.” PLoS ONE 6, no. 2 (2011): e16885.

Ebrahimzadeh Zagami, Samira, Latifnejad Roudsari, Robab and Sadeghi, Ramin. “Quality of Life After Sex Reassignment Surgery: A Systematic Review and Meta-Analysis.” Iranian Journal of Psychiatry and Behavioral Sciences 13, no. 3 (2019): e69086.

Flader, Fr John. “Q&A with Fr John Flader: Assisting transgender children.” catholicweekly.com.au, May 23, 2021. https://www.catholicweekly.com.au/qa-with-fr-john-flader-assisting-transgender-children/.

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).

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Jones, David Albert. “Truth in transition? Gender identity and Catholic anthropology.” New Blackfriars: A Review 99, no. 1084 (2018): 756–774.

Karalexi, Maria A, Georgakisa, Marios K, Dimitrioua, Nikolaos G, Theodoros, Vichosa, Katsimprisa, Andreas, Petridouac, Eleni Th and Papadopoulos, Fotios C. “Gender-affirming hormone treatment and cognitive function in transgender young adults: a systematic review and meta-analysis.” Psychoneuroendocrinology 119 (2020): 104721.

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Nobili, Anna, Glazebrook, Cris and Arcelus, Jon. “Quality of life of treatment-seeking transgender adults: A systematic review and meta-analysis.” Reviews in Endocrine & Metabolic Disorders 19, no. 3 (2018): 199–220.

Passos, Silveira Taciana, Teixeira, Marina Sá and Almeida-Santos, Marcos Antonio. “Quality of Life After Gender Affirmation Surgery: a Systematic Review and Network Meta-analysis.” Sexuality Research and Social Policy 17 (2020): 252–262.

Pham, Dana. “Growing Up Transgender and Vietnamese in Australia.” Dana Pham (blog). Medium, April 07, 2019. https://medium.com/empowered-trans-woman/growing-up-transgender-and-vietnamese-in-australia-3eb4b63285b8.

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Footnotes

[1] Sara Reardon, “The largest study involving transgender people is providing long-sought insights about their health,” nature.com, April 24, 2019, https://www.nature.com/articles/d41586-019-01237-z.

[2] Anna Sapir Abulafia, “The Abrahamic religions,” bl.uk, September 23, 2019, https://www.bl.uk/sacred-texts/articles/the-abrahamic-religions.

[3] Conrad Hackett and David McClendon, “Christians remain world’s largest religious group, but they are declining in Europe,” pewresearch.org, April 05, 2017, https://www.pewresearch.org/fact-tank/2017/04/05/christians-remain-worlds-largest-religious-group-but-they-are-declining-in-europe/.

[4] Catechism of the Catholic Church, 2nd ed. (Vatican City: Vatican Press, 1997), 1803.

[5] Tad Brennan, Routledge Encyclopedia of Philosophy, sv “Telos,” Taylor and Francis, 2002, https://www.rep.routledge.com/articles/thematic/telos/v-1.

[6] “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.

[7] 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.

[8] 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.

[9] William Newton, “Why Aquinas’s Metaphysics of Gender Is Fundamentally Correct,” The Linacre Quarterly 87, no. 2 (2019): 198–205.

[10] Stanford Encyclopedia of Philosophy, sv “Dualism,” Metaphysics Research Lab, September 11, 2020, https://plato.stanford.edu/entries/dualism/#SubDua.

[11] Thomas Aquinas, Summa theologica, trans. Fathers of the English Dominican Province (New York: Benziger Brothers, 1911–1925), Ia, q. 76, a. 1.

[12] Gyula Klima, “MAN=BODY+SOUL: Aquinas’s Arithmetic of Human Nature,” fordham.edu, accessed October 03, 2021, https://faculty.fordham.edu/klima/bodysoul.htm.

[13] Christoph M Zhang, “Biopolitical and Necropolitical Constructions of the Incarcerated Trans Body,” Columbia Journal of Gender and Law 37, no. 2 (2019): 259.

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

[15] Stanford Encyclopedia of Philosophy, sv “Aquinas’ Moral, Political, and Legal Philosophy,” Metaphysics Research Lab, March 16, 2021, https://plato.stanford.edu/entries/aquinas-moral-political/#OtheBasiGood.

[16] Catechism of the Catholic Church, 357.

[17] Metaphysics Research Lab, sv “Aquinas’ Moral, Political, and Legal Philosophy.”

[18] Catechism of the Catholic Church, 358.

[19] Jennifer Beer, “The Inconvenient Truth about Your “Authentic” Self,” Observations (blog), Scientific American, March 05, 2020, https://blogs.scientificamerican.com/observations/the-inconvenient-truth-about-your-authentic-self/.

[20] Taciana Silveira Passos, Marina Sá Teixeira and Marcos Antonio Almeida-Santos, “Quality of Life After Gender Affirmation Surgery: a Systematic Review and Network Meta-analysis,” Sexuality Research and Social Policy 17 (2020): 252–262.

[21] Cecilia Dhejne et al., “Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden,” PLoS ONE 6, no. 2 (2011): e16885.

[22] Kairi Kõlves, “FactCheck Q&A: was Lyle Shelton right about transgender people and a higher suicide risk after surgery?” theconversation.com, March 04, 2016, https://theconversation.com/factcheck-qanda-was-lyle-shelton-right-about-transgender-people-and-a-higher-suicide-risk-after-surgery-55573.

[23] Fr John Flader, “Q&A with Fr John Flader: Assisting transgender children,” catholicweekly.com.au, May 23, 2021, https://www.catholicweekly.com.au/qa-with-fr-john-flader-assisting-transgender-children/.

[24] Dana Pham, “Growing Up Transgender and Vietnamese in Australia,” Dana Pham (blog), Medium, April 07, 2019, https://medium.com/empowered-trans-woman/growing-up-transgender-and-vietnamese-in-australia-3eb4b63285b8.

[25] Anna Nobili, Cris Glazebrook and Jon Arcelus, “Quality of life of treatment-seeking transgender adults: A systematic review and meta-analysis,” Reviews in Endocrine & Metabolic Disorders 19, no. 3 (2018): 199–220.

[26] Maria A Karalexi et al., “Gender-affirming hormone treatment and cognitive function in transgender young adults: a systematic review and meta-analysis,” Psychoneuroendocrinology 119 (2020): 104721.

[27] Samira Ebrahimzadeh Zagami, Robab Latifnejad Roudsari and Ramin Sadeghi, “Quality of Life After Sex Reassignment Surgery: A Systematic Review and Meta-Analysis,” Iranian Journal of Psychiatry and Behavioral Sciences 13, no. 3 (2019): e69086.

[28] Metaphysics Research Lab, sv “Aquinas’ Moral, Political, and Legal Philosophy.”

[29] Aquinas, Summa theologica, Ia IIae, q. 94, a. 2.

[30] E Christian Brugger, “Catholic Hospitals and Sex Reassignment Surgery: A Reply to Bayley and Gremmels,” National Catholic Bioethics Quarterly 16 (2016): 590.

[31] David Albert Jones, “Truth in transition? Gender identity and Catholic anthropology,” New Blackfriars: A Review 99, no. 1084 (2018): 756–774.

[32] Carol Bayley, “Transgender Persons and Catholic Healthcare,” Health Care Ethics USA 24, no. 1 (2016).

[33] 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).

[34] “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/.

[35] Aquinas, Summa theologica, Ia IIae, q. 90, arts. 1, 3.