The current struggle for an appropriate way of dealing with intersex and transgender people touches on a topic that is not only strongly characterised by historical mortgages, serious experiences of injustice and multiple behavioural uncertainties, but also by conceptual misunderstandings, ideological exaggerations, growing polarisation and many unresolved individual practical issues. Even if the reasons for this conflict-ridden situation are certainly manifold, at least some of the problems are likely to result from the enormous complexity of the subject area and the different motivations of those involved in the polyphonic debate on gender issues. While some are primarily concerned with the perception of individual suffering and sensitising society to the special needs of those affected, others have long used the gender discourse to promote particular interests of an economic or (church) political nature. In the competition for public attention, financial resources and political influence, occasionally surprising coalitions and oppositions arise between the groups of actors involved, whereby the dividing lines often run within one and the same academic discipline.
In this context, Catholic moral theology has a twofold task: firstly, it has to scrutinise ad intra its own basic theological and anthropological assumptions as to whether and to what extent they are suitable for integrating new human scientific findings on individual aspects of gender and doing justice to the various moral challenges in this area. Secondly, it has to add its voice to the discourse in society as a whole, for example on appropriate regulations in the area of civil status law or the conditions of access to medical treatment.
My following considerations are largely limited to the first task. Firstly, based on the holistic nature of the biblical view of humanity, the traditional creation-theological concept of the two-gendered nature of human beings will be defended against various misunderstandings and differentiated from attempts to fundamentally overcome the binary gender order. Following this, some ethically significant aspects for dealing with intersex and transgender people will be outlined.
The holistic approach of the Christian view of humanity and bisexuality
Moral theological reflection must mediate the relevant statements of Scripture and tradition for a particular subject area with the contemporary findings of the various human sciences in such a way that the basic coordinates of a Christian view of humanity and the resulting normative orientations emerge as clearly as possible. In doing so, both a defeatist approach to biblical and theological forms of thought, which are supposedly obsolete due to their pre-modern origins, and the naïve invocation of a 'modern state of knowledge', which does not exist in this unambiguous form, especially in the field of gender theory, should be avoided.
Rather, with regard to generalising statements about human beings, it must be assumed that there is no uniform anthropology within the Bible, just as there is no uniform anthropology in the field of contemporary human sciences, whose current findings are "characterised by a pluralism of different rationalities".
complexity". Although the canon of biblical writings contains a multifaceted and exciting juxtaposition of different definitions of the human being and therefore a "complementary and contrastive dialogue" proves to be "constitutive and irrevocable for a hermeneutically, theologically and methodologically responsible biblical anthropology", it is important to remember at least two fundamental convictions that are deeply woven into the biblical texts. One conviction concerns the holistic nature of the human being, the other its bisexual constitution.
In contrast to various dualistic attempts to stylise the physical-material and spiritual-mental dimensions of the human being into two independent metaphysical entities and then to identify the true 'self' of the human being either materialistically or rationalistically with one of them, the biblical authors firstly insist from the outset on the wholeness of the human being, which in the writings of the Torah is interpreted as næfæš in its neediness, bāśār in its frailty and rûa h in its empowerment. In each case, it is the whole person in their concrete physical and spiritual constitution that is illuminated here from different perspectives.
Secondly, thinking in relational categories is no less important. Three basic relationships are of decisive importance for the constellative anthropology of the Bible: firstly, man's relationship to God as his Creator, secondly, to sub-human creatures (such as plants and animals) and thirdly, to his human counterpart. For a closer interpretation of these interpersonal relationships, two influential strands of text must be distinguished. According to the Priestly tradition in Genesis 1:27, humanity was originally created in a two-gender differentiation of 'male' and 'female', whereby an "egalitarian concept of gender difference" is assumed, which is lost again through human guilt and is replaced by hierarchical definitions of relationships.
According to the "non-priestly text in Genesis 2:4b-25, on the other hand, it is not the - sexually differentiated - human race that is formed, but two individual specimens of the species are created from the protoplast, i.e. the still sexually undifferentiated 'human being' (Genesis 2:7), which are subsequently called 'man' and 'woman'". Both strands of text look at the creation event and gender difference from a differently accentuated functional perspective. In the Priestly conception of creation - as Genesis 1:28 shows - the emphasis is clearly on the biological-reproductive function of bisexuality, which as such ensures the continued existence of the species. In contrast, the non-priestly text layer - in the sense of Gen 2:18 - emphasises the lack of self-sufficiency of the individual and the complementary supplementary function of gender difference.
In my opinion, all of these biblical thought motifs - the holistic and relational nature of human beings as well as the reproductive and social function of bisexuality and the normative orientations based on this - are just as significant for the current gender discourse as later theological reflections in the context of differentiated theories of natural law, which, in a productive dialogue with Aristotelian and Stoic considerations on multi-layered human striving, have developed a concept of arbitrary but open-ended natural inclinations (so-called inclinationes naturales). inclinationes naturales), which, in its unresolvable tension between predetermined natural dispositions and the abandonment of rational organisation of life, not only corresponds to a large extent to general human self-awareness, but should also prove helpful in dealing responsibly with the particular conditions of individual sexual development.
Despite important biblical and theological-historical points of reference for our current topic, it must be expressly emphasised in order to avoid possible misunderstandings that an interdisciplinary process of reflection is absolutely necessary in order to mediate these traditions with the requirements of a contemporary concept of 'gender', which as such is able to integrate a whole range of more recent human scientific findings. A contemporary anthropology must not only distinguish between the biological, psychological and social dimensions of gender, but also do justice to the many possible variations within these dimensions. Even at the biological level, several levels have to be taken into account with the respective genetic-chromosomal, gonadal, hormonal and phenotypic conditions, which in the vast majority of cases allow a clear assignment to the male or female pole, but also reveal a number of ambiguous phenomena. The so-called psychological gender is also "a collective term for how a person categorises themselves in terms of gender against the background of their body, their hormonal make-up, their feelings and their biography (including the childhood upbringing phase)"7whereby the respective sexual orientation can take on a bisexual or fluid form in addition to a stable heterosexual or homosexual one. Finally, the social gender role (gender) that an individual assumes due to the interaction of various biological, psychological and social factors can either be in agreement or in conflicting tension with their biological sex (sex).
In view of this complexity of different meanings, some participants in the discourse argue that the concept of gender should no longer be used to designate the integrative unity of all these dimensions within a comprehensive framework of bisexuality, but should be shifted to the level of certain partial aspects such as sexual orientation or the personal feeling of one's own gender identity and thus ultimately be inflated. The term 'third gender', which has already been used occasionally in the past to describe homosexual people, can ultimately be used alongside an infinite number of other genders, as the specific characteristics of the individual gender-constitutive elements naturally vary greatly from person to person.
However, the price for this conceptual manoeuvre, which in my opinion is not very convincing, is extraordinarily high. Not only does it weaken the ordering function of the binary gender system for social interaction, but it also brings with it the risk of new stigmatisation, as the formation of new gender groups is generally by no means value-free, so that the assignment of individuals to certain sexual subcultures is associated with a wide variety of stigmatisations.
prejudices and disadvantages.
Apart from the fact that a strict distinction must be made, both in terms of language and substance, between the general phenomenon of 'gender diversity' - which is compatible with the two-gender thesis - and the very specific idea of a 'diversity of genders' - which abandons the two-gender assumption - a multiplication of genders also has other serious disadvantages beyond the previous bipolar differentiation between women and men, which is certainly open to a wide range of variations. On the one hand, these consist of the danger of a relapse into questionable dualistic ideas of a true gender identity that is supposedly completely independent of the biological and physical circumstances and only accessible to the individual feelings of the person concerned, whose magical-decisionistic implications stand in bizarre contrast to the progressive self-image of the respective protagonists of such positionings. On the other hand, the willingness of some affected groups to increase the number of genders is also based on the illusionary hope, in my opinion, that the introduction of one or more new genders is a kind of master key to solving the diverse and very different practical problems that members of sexual minorities still have to suffer from in everyday life in our society today. However, as the following reflections on the phenomena of so-called intersex and transsexuality show, this expectation is likely to be unrealistic and even prove counterproductive.
Intersex
The term 'intersexuality', introduced by the medical profession at the beginning of the 20th century, served to summarise a variety of different phenomena of ambiguous gender development, which were largely regarded as illnesses requiring treatment. Due to the general pathologisation of these phenomena and the association with extreme medical paternalism, which was accompanied not least by massive deficits in the area of information and counselling for those affected and the justification of certain medical interventions, this term is often avoided today and replaced by the terms 'intersexuality' or 'intersexuality'. In the international scientific context, on the other hand, the more general term differences of sex development (DSD) has become established, which is, however, limited to the biological and physical description of a somatic finding, to which certain disease values or health problems are then secondarily assigned.
Regardless of which of these terms one prefers, it is in any case a collective term that covers very different constellations and therefore deliberately leaves open the question of whether there is a separate gender category sui generis. It is not only medically significant whether the developmental differences are chromosomal abnormalities (such as mosaicism or trisomies of the sex chromosomes), forms of so-called gonadal dysgenesis, anatomical anomalies of the urogenital tract, hormonal disorders (e.g. with hypo- or hyperfunction of the androgens) or phenotypic abnormalities of the primary sexual organs. As a rule, all of this has a very different effect on the individual self-experience of those affected, their perceived subjective level of suffering, their personal ideas of necessary changes as a prerequisite for a successful life and their acceptance by society.
Although greater restraint towards early surgical interventions in intersex children has gradually become established within the medical care system since the Chicago Consensus Conference of 2005 at the latest, this does not mean an end to all relevant controversies between the individual medical associations, nor does this course correction per se guarantee adequate consideration of the numerous non-medical aspects of gender that are equally important for those affected. It is therefore expressly to be welcomed that the German Ethics Council (DER) has, among other things, initiated extensive hearings of and dialogue processes with intersex people in preparation for its 2012 opinion, in order to achieve a better mapping of this multifaceted problem landscape, which, in addition to the classic medical ethical challenges of (in)sufficient information, (lack of) informed consent and careful medication (control), also includes a wealth of other aspects - such as potentially stressful accompanying circumstances, the lack of informed consent and the lack of a medical ethical framework. For example, the potentially stressful circumstances surrounding medical treatment (through photography or the repeated examination of genitals in front of larger groups of doctors and students), the often protracted struggle for reimbursement of treatment costs by health insurance companies and various experiences of discrimination in dealings with authorities, employers and society as a whole. Only for a very small proportion of those affected does the existence of a binary gender system itself appear to be the main source of the problems that burden them. From an ethical and moral theological perspective, a conceptual distinction that DER has based its normative considerations on should therefore prove to be particularly helpful: namely the differentiation between 'gender-ambiguous' and 'gender-assigning' measures based on the depth of intervention.
The first group of gender ambiguity measures includes all medical interventions that aim to align certain physical characteristics, such as anatomical features of the external sex organs, "which exist despite an otherwise unambiguous gender assignment, with the existing gender". In fact, there is a wealth of constellations which, despite certain ambiguities in a person's somatic appearance, allow them to be assigned to the male or female sex relatively easily, so that essentially the only thing left to discuss is what appropriate information and counselling for those affected should look like and at what point in time appropriate medical treatment should be carried out in each individual case in order to minimise the threat of stress in the personal maturation and development process of the person concerned. In contrast, the plausibility of bisexuality itself is not seriously up for debate here because the individual constellations of characteristics are indisputably very close to one of the two poles.
This is different in the - comparatively rare - cases of hermaphroditism verus, in which, for example, the presence of female and male gonadal tissue or ambiguous chromosomal conditions means that classification into a binary gender system is not possible. Extreme caution is required when intervening here, as in the past, the focus of considerations was often neither on the actual well-being of the person concerned nor on taking into account their current needs or the preservation of certain abilities that are valuable to them, but rather on either purely medical-technical (e.g. surgical) opportunities or certain interests of parents and carers. Precisely because an essential part of a person's individual identity is at stake here, they must be involved as far as possible in all relevant treatment decisions. Except in compelling cases of early defence against otherwise imminent serious damage to the child's health, the decision on such far-reaching medical interventions should only be made on the basis of precise indications at a time when the person concerned has the necessary mental maturity to be able to realistically assess the scope of the measures.
With regard to the two-gender thesis, three different constellations must be distinguished: In addition to those intersex people who actually undergo such gender assignment interventions and thus approach one of the gender poles, there are also people who either permanently reject such interventions because they want to preserve their current intersex status quo, or who are not yet in a position to make such far-reaching decisions independently due to their young age.
For these two groups of people, it makes sense to create a separate status under civil status law that dispenses with a clear gender categorisation within the binary system and opens up the possibility of not having to specify a gender status. This approach would not only be far more practicable than attempting to assign the very heterogeneous individual phenomena of intersexuality to different sub-groups, each with their own gender categories, it would also be superior to the current collective term 'diverse' in that it could easily be misunderstood as a separate gender type in the sense of a third gender.
Transgender
The problems are completely different in a second area of phenomena, which concerns people who can be clearly categorised as male or female in terms of their biological and physical appearance, but who reject their birth gender and identify psychologically and/or socially with the complementary pole. In purely linguistic terms, this is referred to as 'gender incongruence', 'gender identity disorder', 'gender dysphoria', 'transsexuality', 'transgender' or 'transgender'. This dazzling terminology also conceals a broad spectrum of different phenomena, ranging from gender-atypical role behaviour in prepubertal children (e.g. cross-dressing) to the temporary struggle of many early adolescents with various developmental tasks (including the realisation and acceptance of their own - possibly same-sex - sexual orientation) to the permanent rejection of their own birth gender and the manifest desire of adults to adapt their own body to the desired gender through hormonal and/or surgical interventions.
target gender.
A convincing approach to these different constellations has to take a whole range of factors into account: In addition to the sometimes considerable subjective suffering of the affected persons themselves, the now well-founded knowledge of child and adolescent psychiatrists, paediatricians and sexual medicine specialists is of particular importance that "by no means all children and (early) adolescents with gender dysphoria and role-nonconforming behaviour inevitably become transsexual". As there has been a significant (sometimes even explosive) increase in the use of relevant counselling and treatment services, especially by young girls, both nationally and internationally in the last two decades, a more precise analysis of the causes is required. The following are cited as important reasons for this development: greater awareness of the problem, persistent gender-specific discrimination, one-sided media coverage, the availability of new pharmacological substances and a medical-technical feasibility mindset with corresponding financial incentives for doctors and clinics. In view of these impact factors, the expertise of the consulted representatives of the healthcare system and the careful differential diagnostic assessment of the respective individual situation are becoming increasingly important. This is all the more true as gender dysphoria can be associated with various affective disorders that make psychotherapeutic support for the adolescents concerned appear advisable and, in addition, "no reliable predictors are currently available that would allow a reliable prediction of the persistence or disappearance of GIS/GD in individual cases".
If the empirical evidence confirms that temporary gender insecurity is indeed "numerically most important in childhood" and that "the most common forms of maturity-related psychosexual developmental conflicts, in particular a rejected homosexual orientation, but also superordinate personality development disorders" occur in adolescence, then this would have far-reaching consequences for dealing with the critical age range of 10 to 13-year-olds who contact medical staff with the desire for a hormonal puberty blockade. The advantage of such a far-reaching measure for the minority of so-called persisters, i.e. those people whose development leads to a later transsexual identity in adulthood, is that their suffering is reduced at an early stage and the cosmetic result of later gender reassignment surgery is improved by suppressing irreversible physical changes caused by puberty. However, this is offset by serious disadvantages for the majority of so-called desisters, i.e. those people who do not have a transgender identity and whose psycho-sexual development is massively impaired by such interventions.
From an ethical perspective, it is therefore not only necessary to exercise the utmost medical care in individual diagnosis and indication, which, due to its demanding nature, should only be carried out in appropriately specialised facilities. This also implies a ban on prophylactic prepubertal hormone treatments, as the presence of an irreversible transgender identity can only be reliably diagnosed after puberty due to the plasticity of gender identity development.
Although there is agreement in principle that the transition of transgender people to the desired target gender should only take place gradually with certain age requirements, there are still widely divergent views on how demanding the conditions of access to the medical interventions required for this should be legally organised in detail. The traditional principle of medical ethics of avoiding harm suggests that strict requirements should be imposed in this context (e.g. with regard to the length of psychosocial testing phases and the obtaining of medical reports), as such treatments are not only extremely cost-intensive and therefore place a considerable burden on the insured community, but are also associated with serious functional impairments for those affected (e.g. loss of their own reproductive capacity and sexual sensitivity). In my opinion, the so-called self-determination law planned by the current traffic light coalition, which would allow 14-year-olds to change their gender entry under civil status law simply by providing information themselves, should therefore be criticised from both a humanities and an ethical perspective.
Conclusion
The considerations made here suggest several conclusions:
Firstly, there is no reason to question the basic coordinates of the Christian view of humanity with regard to the current gender discourse. Both 'wholeness' and 'bisexuality' are well-founded concepts within the framework of which the vast majority of problems that arise in dealing with intersex and transgender people can be meaningfully discussed and resolved.
Secondly, the terms 'intersex' and 'transgender' are pragmatic collective terms that cover a wide range of very different individual constellations, between which there is at best a certain 'family resemblance'. Instead of constantly increasing the number of genders through the questionable isolation of individual elements of the inherently multi-layered concept of gender, the individuality of each person should be taken seriously and anything that increases the risk of new self-induced stigmatisation should be avoided.
Thirdly, it must be admitted that the concept of 'bisexuality' - like all concepts - also has certain marginal blurriness insofar as there are rare hermaphroditism phenomena among so-called intersex people who can actually be assigned to neither the male nor the female gender pole without therefore forming an independent third gender. Whether the persons concerned wish to move closer to one of the two gender poles through appropriate medical interventions or wish to retain their intermediate status should be left to their well-informed individual decision.
Fourthly, it can be assumed that a large number of different practical challenges arise in the context of the diverse variations in individual gender development, which affect very different levels of responsibility and therefore go beyond purely individual ethical reflection. The problems range from necessary improvements in diagnostics, education and counselling for affected individuals by medical staff to the lack of easily accessible psychotherapeutic support services and the reduction of ignorance, prejudice and discrimination against sexual minorities within the population. However, none of these problems can be solved by inflating the concept of gender, as is occasionally suggested on the basis of questionable constructivist social theories or a delimited concept of self-determination. On the contrary, such a strategy can even lead to medical professionals increasingly distancing themselves from their professional ethical responsibility to care, to the detriment of patients, and basing treatment on purely economic interests or unreflected
self-harming wishes of those affected.
Fifthly, in view of the clearly pronounced and sometimes aggressively expressed defensive attitude of some trans activists towards the use of medical terminology, it must be expressly emphasised that a careful differential diagnostic description of the respective individual constellation and a meticulous assessment of indications by appropriately qualified medical professionals is a necessary condition for responsible action in this particularly sensitive area. Anyone who believes that they can use the blanket accusation of 'perpetrator language' to dispense with the basic insights of medical theory and stylise their own preferences as an unquestionable right to the provision of medical services is not only disregarding the generally binding normative principles of the medical care system, but also the different functions of doctors and patients within the process of responsible treatment planning (in the sense of shared decision making).
Sixthly, from a general ethical perspective, it should be remembered that the overarching goal of a successful lifestyle should primarily be geared towards developing and strengthening one's own individual capacity to act. Instead of using premature interventions to encourage young people to fixate more and more on certain, ultimately fated, natural conditions of their own gender identity, the focus of therapeutic support programmes should be placed primarily on important developmental goals beyond their own gender identity.
Seventhly, from a theological perspective, it can generally be assumed that the tried and tested normative rules for a reliable partnership also apply to intersex and transgender people, so that there can be no question of a special morality for this group of people. Furthermore, in view of the very different individual burdens of those affected, it must be made clear on a doctrinal level how the 'whims of nature' manifested in the variants of gender development can be reconciled with the Christian belief in a good Creator God. On the other hand, at a pastoral level, care must be taken to ensure that those affected not only encounter openness and empathy in the parishes, but also have access to spiritual offerings that enable or facilitate both self-acceptance and self-transcendence for them - as for all other parishioners. 
