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NOT HERE: Catholic Hospital Systems and the Restriction Against Transgender Healthcare.

Surgical interventions to facilitate transgender people's medical transitions were excluded from most private health insurance policies in the United States beginning in 1979, and from Medicare and Medicaid coverage beginning in 1981. For decades, Americans seeking transition-related surgical care either paid for that care out of pocket or, more frequently, went without it. (1) Over the past five years, however, public and private health insurance coverage for transition-related surgery has increased exponentially. (2) As available funds have increased, so has demand for services. (3) American institutions are now struggling to meet a growing demand for competent, efficient, and effective transgender healthcare that they had denied for decades.

At the same time that demand and funding for transgender healthcare is expanding across the country, the number and market share of Catholic-owned hospitals is also growing. Between 2001 and 2016, the number of U.S. hospitals affiliated with the Catholic Church increased by 22 percent (Uttley & Khaikin 2016). By 2016, one in six acute care beds in the United States was in a Catholic hospital, and in some states, more than 35 percent of all hospitals were affiliated with the Catholic Church (ibid). Multibillion-dollar hospital system mergers led one recent commentator to ask if 2018 would be "the year of Catholic hospital dominance (Fig. I)." (4)

The rapid expansion of Catholic hospitals is a concern for transgender people, their advocates, and the insurers who provide their health coverage because Catholic hospitals do not provide transition-related care. A recent commentary on "Insurance Coverage and Transgender Care" in the Catholic Health Association magazine, Healthcare Ethics USA, put the matter plainly: "The fact that insurance companies are providing coverage [for transition-related procedures] certainly does not mean that these treatments, or even the diagnosis, are clinically appropriate or morally acceptable" (HCE 2017: 34). The conflict between patients' demand for procedures that are recognized as medical best practice among numerous American medical organizations (5) but are identified as religiously unacceptable among conservative Catholics has resulted in several legal actions against the church in recent years. Law suits have provoked theological and ethical debates that make Catholic rationales for refusing transgender care explicit.

In this article, I examine how the liceity of transgender surgical procedures has been discussed by contemporary American Catholic bioethicists, with attention to how they justify and explain ongoing denials of care. As I will show, Catholic debates about the ethical status of transgender healthcare contribute to the surging American discourse of "religious liberty," in which it is "freedom of conscience" that exempts Catholic institutions from the duty of providing best-practice medicine. This line of argumentation, well rehearsed with regard to reproductive and end-of-life care, is being newly and somewhat differently applied in the case of transgender medicine. I argue that within this discourse, the contentious status of the transgender body is used as a moral lever to expand the penumbra of "conscience-based" exemptions beyond the issues of life and death that have dominated Catholic healthcare debates for decades.

The Ethical and Religious Directives for Catholic Healthcare Services

The United States Conference of Catholic Bishops (USCCB) delimits the services provided in Catholic hospitals through a set of guidelines called the Ethical and Religious Directives for Catholic Healthcare Services (ERD). First published in 1948, the fifth edition and the most recent edition of the ERD published in 2009 state that they are a set of "theological principles that guide the Church's vision of healthcare" (UCCB 2009: 3). Variously interpreted and inconsistently applied in their early iterations, the promulgation of ERD began in earnest in 1973, following two pivotal events. The first was the decision in Roe v. Wade in which the U.S. Supreme Court affirmed a woman's right to have an abortion within the first two trimesters of pregnancy. Immediately following Roe, the U.S. Congress passed the Church Amendment into law, the first American "conscience clause" exempting private hospitals from requirements to provide abortion or sterilization services to which they held moral or religious objection (Dubow 2015).

Leaders of the Catholic hierarchy understood the new conscience clause as a vital protection of their beliefs and were attuned to what the law demanded. In their history of the development of the ERD, O'Rourke et al. (2001:19) write that "Cardinal John Rrol of Philadelphia, then NCCB [National Conference of Catholic Bishops] president, pointed out to the bishops that they might have a difficult time using the federal conscience clause allowing hospitals to prohibit abortions and sterilizations in accord with "religious teaching" unless they were on record as prohibiting such procedures." The ERD were an important tool in establishing a defensible and distinctly Catholic position on the issue of abortion and other ethical questions that arose in their role as hospital administrators.

In addition to Directives advising on the pastoral role of healthcare, the administration of baptism and last rights to the dying, the ERD also include some attention to specific medical procedures and related ethical questions. These are focused on issues of life and death, including guidance on organ transplant, on acceptable responses to conception and pregnancy (management of assisted reproductive technologies, abortion, ectopic pregnancy, and embryonic research), and ends of life (including euthanasia, and life-extending technologies). Each time the ERD are revised, new issues and questions are addressed (O'Rourke et al. 2001). The basis on which they are revised is claimed as a continuation of deeply held Catholic commitments. "The moral teachings that we profess here," the ERD state, "flow principally from the natural law, understood in the light of the revelation Christ has entrusted to his Church. From this source the Church has derived its understanding of the nature of the human person, of human acts, and of the goals that shape human activity" (United States Conference of Catholic Bishops 2009: 4).

Practical adherence to the letter of the ERD is enforced by the bishop of each diocese, and consequences of deviating from its directives can be swift and significant. In 2010, when an Arizona hospital performed an abortion in order to save the life of a pregnant woman with severe pulmonary hypertension, the Diocese excommunicated the nun who was then senior administrator of the hospital and stripped the institution of its Catholic affiliation (Tanne 2010).

There are no specific directives in the ERD regarding transgender surgical interventions. One Catholic ethicist wrote in 2016 that "As anyone knows who has tried to research the teachings of the Catholic Church on the questions of transgenderism, these are questions on which the Church has not written directly or publicly" (Bayley 2016:3). (6) Still, decisions about interventions are made every day in the course of medical practice. Ethicists and administrators make reference to the ERD and its binding power when discussing the liceity of trans-surgical interventions, a discussion they have been having in earnest.

Justifications and Explanations of Denials

Explanations for why transition-related surgeries should not be allowed in Catholic hospitals invoke theological principles, as well as political ones. Catholic ethicists levy theological objections based primarily on assertions of a Catholic anthropology (informed by claims to Natural Law) that does not recognize the distinction between body and soul that they understand to characterize the transgender medical project. They further argue that reproductive sterilization that may result from surgically altering reproductive organs in the service of transition is morally impermissible. Political objection to transition-related surgeries appears in calls to resist on principle the corrupting influence that "popular" opinions--including those of institutional actors like medical associations and insurers--might have on the church. Ethicists specifically name a refusal of transgender medicine as an important stand for Catholics in America and see the expansion of Catholic hospital systems (and the things they will not do) as an important tool for the defense of their beliefs.

Theological Objections

The most frequently argued position against the provision of transgender surgical services is that doing so participates in an understanding of the human person that conflicts with a distinct Catholic anthropology. The Catholic understanding of the human person is as an irreducible body-soul unity. In contrast, the conceptualization often used to explain the transgender desire for surgical transformation--that a person's sense of gendered self is misaligned with their body's manifest characteristics--is predicated on a distinction between self and body. "Any claim that the rational soul is a mere pilot within the body," writes NCCB ethicist Edward Furton, "or that the body is nothing more than an instrument or container for the soul is contrary to Catholic teaching" (2017). Such "substance dualism," Bedford (2016: 26) write, "is incompatible with a Christian anthropology and so is any justification built upon it." "To argue that TG [transgender] surgery integrates a human person," they continue, "one must presume that the alleged ontological dis-integrity actually exists. The strong thrust of the Catholic philosophical tradition indicates that this is not plausible" (27). "This conclusion," concurs Jacob Harrison, "suggests that future arguments for the permissibility of SRS in Catholic healthcare will always be invalid if they fail to uphold the body-soul unity of the person" (Harrison 2017: 291).

Conceiving a body-soul unity in which both body and soul are immutably sexed and gendered (Bedford 2016), many Catholic ethicists argue that changing sex is impossible. The National Catholic Bioethics Center (NCBC) website asserts that "A person is the unity of soul and body, and "soul" should be understood not as an immaterial self, but as that which makes the body be what it is, namely, a human person. We are either male or female persons, and nothing can change that." (7) The NCBC position statement on transgenderism asserts that "Directly intending to transition one's given bodily sex into a "new" one (even though this may be perceived as the "real" and "true" one) means intending to alter what is unalterable, to establish a false identity in place of one's true identity, and so to deny and contradict one's own authentic human existence as a male or female body-soul unity" (2016: 601). As such, "A person can mutilate his or her genitals, but cannot change his or her sex. Changing one's sex is fundamentally impossible; these procedures are fundamentally acts of mutilation." (8) Staff ethicist at the National Catholic Bioethics Center, John A. Di Camillo writes "In the end, there is no authentic transition either anthropologically or biologically--just mutilation" (2017).

While Natural Law is invoked as a basis for the claim that all humans are made by God as either male or female, other times scientific discourse is called upon to bolster the position. (9) "It would be wrong to affirm the falsehood that manifestly biological males are ever female, or vice versa," wrote E. Christian Brugger, then a theological consultant to the U.S. Conference of Catholic Bishops' Committee on Doctrine (Brugger 2016: 590). "Changing our biological sex is impossible... our sex is written into every one of our roughly sixty trillion cells. SRS is, therefore, a pretender's game" (592). Richard Fitzgibbons, a psychiatrist and author of a book expressing the Catholic defense of "one man, one woman" marriage, writes that "Sexual identity is observed at birth and, except in rare cases, matches the genetic structure. It is written on every cell of the body and can be determined through DNA testing. It cannot be changed. Calling men who have had SRS 'women' does not change their genetic structure. It does not make them genetic women" (Fitzgibbons et al. 2009: 98).

Claims that sex is fixed and immutable thus appear in Catholic bioethical debates in two distinct discourses--theological and biological--that understand the ontological status of sex in fundamentally different ways. Importantly, neither of these--body-soul or genetic--are the kinds of sex that may be altered in practices of transgender medicine, and I am not aware of any advocate of transgender medicine who suggests that medical intervention is meant to change them. Instead, it is the subjective experience of sexed embodiment and the fact of sex as a social identity that is transformable through practices of hormone replacement and surgical reconstruction. The work of bioethical argumentation here is to claim for the Church the authority to define sex itself against what ethicists portray as a growing swell of false evidence and misguided sentiment that would define it otherwise. As growing demand for transgender surgical procedures meets the growth of Catholic-owned hospitals, a dispute has opened about who has the authority to characterize the transgender surgical project and it. On the side of Catholic bioethicist, this dispute has facilitated the means by which a newly articulated definition of sex might take its place next to life and death as beliefs the Church can claim are protected by right of conscience.

As Sterilization

Some Catholic ethicists reject the practice of transgender medicine because it results in sterilization that is prohibited by ERD directive 53 (Di Camillo 2017: 220). Often, rejections on the grounds of sterilization appear in the same texts as those that argue for rejection on the grounds of the body-soul unity. This double claim emphasizes that even if one were to reject the theological assertion, Catholic hospitals still could not participate based on a long-standing, widely acknowledged, and legally protected refusal to participate in surgical sterilization. "SRS is the most radical form of sterilization, and according to Catholic moral teaching, it is unethical on that ground alone," writes Richard Fitzgibbons et al. (2009: 99).

The argument that transgender surgery constitutes impermissible sterilization, per se, is factually incorrect, but it is a rhetorically expedient way to justify the rejection of transgender medicine as a new instance of a procedure whose conscience-based exemption is well established. In fact, many surgical procedures undertaken in the process of transgender transition do not involve the reproductive or genital anatomies. (10) The inaccurate conflation of transgender surgery with sterilization allows those opposed to transgender surgery to categorize it as one of what defenders of religious conscience claims call the "most contentious medical cases: abortion, assisted suicide, capital punishment, contraception, fertility treatments, and sterilization" (Butterfield and Taub 2017:416). This strategy, as I've shown, is a way to move transgender medicine into the group of conscience protected, "most contested medical cases" by false association.

Acknowledging that not all transition-related procedures result in sterilization, Rev Benedict Guevin (2009) argued that directives against sterilization should not be the grounds on which transition-specific procedures are refused. In his argument, Guevin reframes medical transition as a multistep process involving many interventions and lays claim to the illicitness of all of them, whether or not sterilization is the result. In response to a 2009 lawsuit filed in California by a transgender woman whose request for a breast augmentation was denied by a Catholic hospital, Guevin argued that "augmentation mammaplasty on a male is, in fact, part of the 'transgendering' process and therefore illicit for a Catholic hospital to perform" (2009). For Guevin, although the addition of breast forms clearly does not result in reproductive sterilization and does not constitute the same kind of "mutilation" involved in removing and repurposing structures in genital reconstruction, its role in the "transgendering" process renders it illicit. He claims that breast augmentation violates principles of integrity and totality "by introducing on a male chest silicone implants that serve no purpose in the functioning of the whole person as a man" (Guevin 2009: 457). Guevin concludes his article on this question by arguing that Catholic hospitals should be legally protected from having to provide "transgendering" procedures by making an analogical link to another currently protected procedure. "Legislation that currently protects Catholic hospitals from having to perform abortions," he writes, "should be expanded to include transsexual reassignment surgery in all its stages" (458).

Because abortion was the issue that originally motivated the establishment of conscience clauses and organized the Catholic Church's support and promulgation of the ERD as a doctrinal statement on healthcare-related beliefs, it is frequently the issue to which other conscience-based claims are analogized. Just as we reserve conscience-based exemptions from the obligation to perform abortion, the argument goes, so should we around x. This suggests facile commonalities among procedures that are grouped not by the characteristics inherent to them, but by the fact that the Catholic Church objects to them. Likening Catholic doctrine to conscience creates a precedent by which other medical interventions can then be compared: Catholic-as-conscience on one side, and all-things-analogized-to-abortion on the other. The mutually constitutive categories of good and evil represented in this dynamic make it difficult to attend to the specificity of how those categories are made and maintained, and how particular procedures find their way to one side of the line or the other.

Refusal as Righteous Resistance

The refusal to provide transition-related surgical treatments for transgender people is often vaunted in Catholic ethics literature as a principled stand against a "popular" worldview portrayed as dangerously encroaching on Catholic freedom of conscience. Such a portrayal depends on framing the church as an embattled minority struggling to maintain its ancient and deeply held principles in the face of secular society driven by trends and fashion. In an article arguing against Obama-era policies aimed at disallowing healthcare discrimination against transgender Americans, Ryan Anderson opens with an (unsubstantiated) anecdote: "On New Year's Eve 2016, a group of Roman Catholic nuns breathed a heavy sigh of relief" when "a federal judge placed a nation-wide injunction on a Department of Health and Human Services (HHS) mandate that would have forced all healthcare plans regulated under Obamacare to cover sex-reassignment procedures, and that would have forced relevant healthcare workers to perform them. Because of the judge's ruling, the hospital run by the nuns would be safe" (2018). Scores of negative health disparities among transgender Americans have been well documented for decades, and their persistence was a significant driver of efforts to disallow gender-based discrimination in healthcare. In Anderson's scenario, however, it is the safety of the Catholic Church itself--through the metonym of the ostensibly vulnerable group of nuns--that is the cause of concern. These nuns--the question of whose actual existence matters less than the rhetorical use Anderson makes of them--narrowly escaped what we are to believe was a terrible fate.

Calls to resist "popular" beliefs are central to the surging American discourse of religious liberty. Marie Hilliard, the current director of Bioethics and Public Policy at the National Catholic Bioethics Center, wrote in 2012 that "protecting the conscience rights of health-care providers is the bell weather topic for freedom" (Hilliard 2012: 318). While Hilliard was writing about "pregnancy centers," the sentiment she expressed has been expanded to the discussion of transgender healthcare. Commentator Christian Brugger emphasized the risks that changing ideas about gender pose to Catholic hospitals. "There is a great danger that practitioners and administrators at Catholic hospitals will too succumb to this intense social pressure to affirm, or at least not oppose, erroneous assumptions about human nature, sex, gender, and psychology and so begin prescribing and performing practicably irreversible surgical interventions that are defensible by neither good morals nor good medicine" (Brugger 2016: 597). For him, the Catholic Church is thus outside and prior to "the social" and so must resist its new and unwelcome advance.

Some Catholic commentators complain that they are subjected to unfair criticism when they reject the "popular" beliefs that transgender people can speak with authority on their own behalf and have a right to seek and receive healthcare. "Those who believe that it is impossible to change a person's sex do not want to be insensitive to others, but neither should they be forced to lie by calling a man a woman or by calling a woman a man. Transsexual activists hope to force the public to use pronouns and designations of the sex the person wants to be rather than their true sex, even when the person has not undergone SRS. They want those who refuse to accept sex changes to be labeled as 'transphobic'--and charged with discrimination" (Fitzgibbons et al. 2009: 123). Brugger (2016: 597) wrote that "Catholic hospitals must resist this temptation [to respond to popular demand for transgender care], even if in so doing they experience criticisms from their secular counterparts." Holding fast to the mantle of "tradition," refusals to budge against this "intense," "activist," "force," of "popular," "secular," "social pressure" glossed by Pope Francis in 2016 as "gender ideology," is revered as virtuous, and helps to frame the church as the victim of a serious and encroaching threat. (11) The Christian Medical and Dental Association (CMDA) asserts that its "traditional view has become counter-cultural" but that "God's design transcends culture" (2016).

Hospital Ownership as a Tool for Advocating Catholic Doctrine

Acts of resistance, among which The National Catholic Bioethics Center includes refusals to require hospital employees to use personal pronouns in accordance with a patient's wishes, are valued for the transformative role they might have in social life (NCBC 2016: 602). The NCBC identifies the influential power of the Catholic hospital system as one means by which it might "effectively counter the societal influences of powerful elitist groups" that advocate what it calls "gender theory." In an overview on its website, NCBC ethicists write "The two largest nonprofit healthcare delivery systems in the country--Ascension and Catholic Health Initiatives--are both Catholic. One-sixth of all the hospital beds in the United States are Catholic. And there are estimates that half of all social services in United States are provided by the Catholic Church. If all these incredibly powerful and pervasive Catholic institutions [including Catholic schools and universities] were faithful to the teachings of the Church, they would wield a considerable cultural influence at every level of society." (12) In the very same numbers that worry advocates of transgender health, Catholic ethicists see opportunity.

In early 2017, the Ascension and St. Joseph's Providence Health systems considered a merger that, although ultimately scuttled, would have created the largest single provider of healthcare in the United States. In December 2017, a separate merger was announced between Catholic Health Initiatives (CHI) and Dignity Health Services (DHS). (13) Expected to close by the end of 2018, the new $28 billion system would include more than 700 facilities in twenty-eight states. (14)

The growing number of mergers and acquisitions among Catholic hospital systems are driven by financial incentives, but there are compelling religious reasons for Catholic hospitals to merge together rather than with non-Catholic hospitals. (15) "New partnerships," the ERD state, "can pose serious challenges to the viability of the identity of Catholic-healthcare institutions and services, and their ability to implement these Directives in a consistent way, especially when partnerships are formed with those who do not share Catholic moral principles. The risk of scandal cannot be underestimated when partnerships are not built upon common values and moral principles" (United States Conference of Catholic Bishops 2009: 35). Because health and hospital system mergers, collaborations, and joint investments can be so complex--from shared technology, to delivery systems, to common real estate--it can be difficult to ensure that all facilities owned or operated in cooperation with the Catholic hospital uphold the ERD. "Because of the potential dangers involved in the new partnerships that are emerging," the ERD continue, "an increased collaboration among Catholic-sponsored healthcare institutions is essential and should be sought before other forms of partnerships" (United States Conference of Catholic Bishops 2009: 35). Any formal collaborations with an institution that provides "transsexual operations," writes ethicist Corinna Delkeskamp-Hayes (2001:13), would be a slippery slope endangering the moral standing of the church.

Conclusion

An evaluation of the veracity or principled accuracy of the claims made by the ethicists I cite here is beyond the scope of this essay. Instead, my interest is in understanding how new conditions of healthcare financing and delivery have hastened the creation of an ethical position in the Church and, given the rapid expansion of Catholic hospital ownership, how that position impacts the practical delivery--or withholding--of healthcare from transgender people. The effects of Catholic hospital ownership on reproductive medicine have been well documented. (16) New insurance coverages are bringing prospective transgender patients into healthcare systems in numbers significantly higher than just five years ago. It is important to understand how the politics of hospital administration will shape the kinds of care that is available to them, or not.

I have shown the ways that newly debated positions on transgender medicine depend on marshaling claims about the nature of sex that had not been articulated in these ways before. This is not altogether surprising because the advent of new medical interventions provokes debates about their ethical status that draw upon earlier principles for guidance. Transgender surgical procedures have been practiced in the United States since the 1960s, well before 1973 when the ERD became a central tool in the establishment of Catholic positions on matters of medicine for which they would claim conscience protections. In all the iterations of the ERD since that time, definitions of sex and the licitness of transgender medicine have never been included. As funded patient demand grows, ethicists are working in many different ways to argue for why Catholic hospitals will not participate. They've done this by claiming that the concept of transgender itself violates principles of Catholic anthropology, by warning away from it as illicit sterilization, by analogizing it to procedures for which conscience protections already exist, and by staging it as a line in the sand for claims to religious liberty. These efforts do not simply reveal and explicate settled doctrine that already exists, for it manifestly does not. Instead, this work has been about making newly articulated objections seem old and deeply held.

The emerging pronouncements about the nature of the transgender body that I discuss here are fundamentally shaped by ongoing U.S. debates about gender, politics, and religion. U.S. law exempts medical institutions and individual practitioners from performing procedures that conflict with their deeply held religious beliefs, and efforts to expand the scope of those protections are ongoing. While conscience-based protections for Catholic providers have been centered around the issues of life and death that are clearly articulated in the ERD, new debates about transgender medicine are providing a forum for efforts Catholic ethicists to expand the scope of conscience-based exemption. Doing so requires establishing as a deeply held Catholic belief a definition of sex whose articulation was necessitated by new patient demands. The effects of these efforts will impact a growing number of Americans who turn to Catholic hospitals not because of shared faith, but in need of healthcare. It is an open question whether these hospitals will provide that healthcare, and on what basis they might make decide to do so, or not.

Notes

(1.) After a court found in 1979 that a trans-woman's private insurer could not reject her claim for genital reconstruction on the grounds that it was a cosmetic surgery, many private insurers added explicit exclusions of transition-related procedures into their contracts (Davidson v. Aetna Life & Casualty Insurance Co). In 1981, the U.S. Department of Health and Human Services excluded "transsexual surgeries" from Medicare coverage, calling the procedures "controversial," and, "because of a lack of well controlled, long-term studies," found the procedures to be "experimental" and thus not covered (140.3, Transsexual Surgery. NCD Record at 93. 54 Fed. Reg. 34,555, 34,572 (August 21, 1989)).

(2.) The Human Rights Campaign reports that 647 major U.S. employers provide transgender-inclusive health benefits, including 50 percent of Fortune 500 companies in 2017, up from zero in 2002 (HRC 2016). Following a lawsuit in 2014, Medicare overturned its 1981 exclusion of "transsexual surgery," making claims to surgical services possible under that program (U.S. HDDS 2014). Eighteen states plus DC provide transgender-related healthcare coverage to state employees (MAP 2017). Public coverage via Medicare and Medicaid is also increasing, largely due to legal mandates for services under a 2014 Medicare coverage determination and a 2016 rule declaration pursuant to the Affordable Care Act. In 2013, three U.S. states and the District of Columbia had prohibited the exclusion of transgender-related services from private insurance plans operating in their jurisdictions. By 2016, fifteen states had done so (Keith 2016). According to the Movement Advancement Project, as of late 2017, twenty-one U.S. states had no explicit policy regarding transgender health coverage in their Medicaid programs, and fifteen states explicitly exclude transgender coverage from their Medicaid coverage (Movement Advancement Project 2017).

(3.) One study found a 20 percent increase in demand for surgical services between 2012 and 2014, with those seeking to use Medicaid or Medicare funding up threefold in that time (Canner 2018).

(4.) Miller, Patricia. January 2, 2018. http://rehgiondispatches.org/will-2018-be-the-year-of-catholic-health-care-dominance/. Accessed on February 10, 2018.

(5.) Including the American Medical Association, American Psychiatric Association, American Psychological Association, The American Academy of Child and Adolescent Psychiatry, American Academy of Family Physicians, American College of Nurse Midwives, American College of Obstetricians and Gynecologists, and World Professional Association for Transgender Health.

(6.) In fact, the Catholic Church began to publish statements regarding the status of the transsexual person following surgical sex reassignment in 1997. In the essay, "Transsexualism and the Canonical Order," Navarrete (2014) explicitly set aside the ethical and moral questions of the permissibility of surgery in order to attend to the potential effects of surgical transformation on canon law. Though not addressing the question of whether Catholic-hospitals ought to perform such surgical interventions, these early commentaries on transsexualism helped to establish a particular Catholic understanding of surgical efficacy, including the claim surgery cannot change one's sexual status in Church matters such as ordination and marriage, and that the body parts produced through reconstructive surgery are not legitimate because they do not enable reproduction. Navarete's essay was first published as "Transexualismus et ordo Canonicus," in Periodica de re canonica 86(1): 101-24 in 1997. Its first authorized English translation appeared in The National Catholic Bioethics Quarterly 14(1): 105-18 in 2014.

(7.) https://www.ncbcenter.org/resources/frequently-asked-questions/gender-identity-disorder-and-sex-change-operations/. Accessed on July 11, 2018.

(8.) https://www.ncbcenter.org/resources/frequently-asked-questions/gender-identity-disorder-and-sex-change-operations/. Accessed on July 11, 2018.

(9.) The existence of persons born with intersex conditions is acknowledged, but it is generally asserted that while it may be complicated to determine the true sex of the intersex person, they do in fact have a true and binary sex.

(10.) Increasingly, too, healthcare providers in non-Catholic institutions assist transgender people whose interventions may compromise their reproductive capacity to participate in fertility preserving procedures such as gamete banking (Chen et al. 2017, Jones et al. 2016).

(11.) For a more robust discussion of "gender ideology" in the Catholic Church, see the 2016 special issue of Religion & Gender 6(2), edited by Sarah Bracke and David Paternotte dedicated to the topic.

(12.) National Catholic Bioethics Center. Transgenderism: Overview--how did we get here? Online https://www.ncbcenter.org/files/3115/2459/5858/2017-Cultural_Overview.pdf. Accessed on July 11, 2018.

(13.) In addition to the evaluation and oversight of these mergers by regional church hierarchy, the Vatican can be asked to review and evaluate whether proposed hospital mergers meet the burden of proper adherence to the Ethical Directives. The Vatican has not yet rendered a decision about the proposed merger between CHI and DHS (Evans 2018).

(14.) Evans, Melanie, May 14, 2018, Is This Hospital Takeover Permitted? Ask the Catholic Church? The Wall Street journal Online, https://www.wsj.com/articles/is-this-hospital-takeover-permitted-ask-the-catholic-church-1526290201. Accessed on July 11, 2018.

(15.) The trend of increased mergers and acquisitions is not limited to Catholic systems. Bloomberg reported record activity in healthcare mergers and acquisitions, reaching $156b in the just the first three months of 2018 (Baigorri 2018).

(16.) See ACLU 2016 and Hafner, Katie, August 10, 2018, As Catholic Hospitals Expand, So Do Limits on Some Procedures, The New York Times, https://www.nytimes.com/2018/08/10/health/catholic-hospitals-procedures.html. Accessed on September 13, 2018.

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Author:Plemons, Eric
Publication:Cross Currents
Article Type:Viewpoint essay
Geographic Code:1USA
Date:Dec 1, 2018
Words:6035
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