kaiser gender reassignment surgery

In her public appearances, Cole describes herself as a "detransitioner" — that is, a person who had second thoughts about transitioning from their gender assigned at birth and has chosen to go back.

She claims, however, that in her case there's no going all the way back — she had a double mastectomy while transitioning from female to male, and says that the hormones and puberty blockers she took along the way have left her with permanent health problems.

It's impossible to know at this juncture how much of Cole's narrative unfolded as she says, how much of what she views as medical malpractice is due to her or and her parents' misunderstanding; her lawsuit is 32 pages of pure accusations. Kaiser, for the moment, can't discuss Cole's case without her express permission because of federal and state patient privacy laws.

That might change when Kaiser files a formal response to the lawsuit, which could be weeks or months from now. For the moment, all Kaiser is willing to offer is a generic statement that it "provides patient-centered gender-affirming care that is consistent with the standards of medical care and excellence [and] .... founded on sound research and best medical practices" for all transgender patients including adolescents.

The context of Cole's lawsuit bears close scrutiny. It's part of a concerted right-wing attack on LGBTQ rights, in which the health of transgender youth is exploited as a pretext for bans on gender-affirming care. It resembles the right-wing attack on abortion rights, another movement that cynically masquerades as an effort to improve healthcare but actually exposes millions of Americans to injury and death for strictly partisan purposes.

In this case, too, the targets are not only the patients themselves, but their families. Treatment bans and efforts such as an attempt by Texas officials to prosecute gender-affirming care as "child abuse" terrify parents seeking to obtain information, counseling and therapy for their children who may be grappling with physical and psychological challenges.

"Their fear is always around accessing the care that kids are already receiving and being able to continue medication they've been on with success," says Maria Bruno, public policy director of the LGBTQ advocacy group Equality Ohio.

Cole is one of a handful of self-described detransitioners who have been flown around the country by anti-transgender activists to speak in favor of treatment bans. Their presentations aim to convince legislators that second thoughts are common among transgender patients, as though to suggest that gender-affirming treatment is a sham.

In fact, studies indicate that only 1% to 2% of transgender individuals "detransition," and that often happens because of discrimination and other social pressures, not because the patients genuinely feel they have made a mistake about their gender identity.

Proponents of these bans assert that puberty blockers and hormones used in such care endanger the lives of adolescents. They say the youths may be going through a phase that they'll soon outgrow and the treatments are based on overly indulgent diagnoses of "gender dysphoria" — that is, the psychological distress caused by "an incongruence between one's sex assigned at birth and one's gender identity," in the words of the American Psychiatric Assn.

The truth is just the opposite. Gender dysphoria diagnosis is neither novel nor a fad, as some partisan critics assert. Instead, it's recognized by professionals as a serious medical condition.

"Gender-affirming care and treatment for gender dysphoria has been provided in the United States for decades," says Kellan E. Baker, executive director of the Whitman-Walker Institute, a Washington research center and provider of health services to the LGBTQ community.

These treatments are administered according to professional protocols and guidelines of long standing, Baker says. The standards of care for children prior to the onset of puberty (which happens on average between the ages of 9 and 11 ) call for "social support," meaning "listening when a kid tells you who they are," he told me.

The onset of puberty "can be extraordinarily distressing for transgender children," Baker says. That's the period when irreversible physical changes emerge that can conflict with the young person's gender. "It's well known that this can cause depression, anxiety, suicidal ideation, and other challenges that can be life-threatening for young people who are going through the wrong puberty."

Drugs can be administered at that stage to delay or pause puberty. "They don't have irreversible physical effects," Baker says. "When you go off them, puberty resumes." Adolescents who suffer from gender dysphoria take puberty blockers "to give them time to work with clinicians, mental health professionals and their parents to make sure they are on the right track."

Professional guidelines call for hormone therapy — such as testosterone for female-to-male transition and estrogen for male-to-female — to begin around the age of 15 to 16. Surgical interventions aren't indicated for people under 18, except in very rare cases in which dysphoria is so severe that it can't be mitigated any other way. "Typically, surgeries are performed in adulthood," Baker says.

Put it all together, and the bans on such treatments prior to adulthood being pushed by conservatives deny them to people at the moment when they're most in need.

For many patients, outlawing the use of therapeutic hormones until adulthood or the use of puberty blockers on children, as is mandated by laws and regulations passed in some states, condemns them to living with a serious medical condition that could have been alleviated through medical treatment.

"I was a trans kid who grew up here, and I would not have survived if I wasn't able to access the gender-affirming healthcare I desperately needed," Ohio resident Aaron Demlow, 24, told a committee of that state's House of Representatives last May, when it was considering a ban. "Gender-affirming care saved my life at 16."

The proposed ban appeared assured of passage but failed to cross the finish line before the legislative session expired; it has been reintroduced this year and is again expected to pass and become law.

The minds of politicians and ideologues supporting prohibitions on gender-affirming care are impervious to similar appeals from patients and parents or to the weight of professional evidence favoring treatment. The hearings on Ohio's proposed ban drew 26 proponents and 289 opponents.

Then there's Florida, a state where sound medical science gets obliterated by conservative politics (as evidenced by the state's campaigns against COVID-19 treatments and vaccination ).

At a hearing last month by the state boards of medicine and osteopathic medicine, Democratic state Rep. Rita Harris read off a list of 22 professional bodies, including the American Medical Assn., that opposed restrictions on young persons' access to gender-affirming care.

"That's quite a group of people to go against and say you don't agree," she said.

The boards voted to confirm a ban on puberty blockers and hormone replacement therapy for minors originally proposed in June, and even removed an exemption for treatments undertaken as part of clinical trials. The state Legislature soon will take up a bill placing the ban in state law.

In June, Florida's Medicaid program banned coverage for gender-affirming care. Last April, the state's crackpot surgeon general, Joseph Ladapo , recommended against puberty blockers and hormone treatments for anyone under 18, a stand contradicting the recommendation of the U.S. Department of Health and Human Services .

Nearly a dozen scientists whose work was cited in Ladapo's memo said he had misrepresented their research , which tended to support, not discourage, those treatments. An open letter signed by 300 Florida specialists in transgender care said Ladapo's recommendation "misrepresents the weight of the evidence, does not allow for personalized patient and family-centered care, and would, if followed, lead to higher rates of youth depression and suicidality."

Cole has addressed public events with right-wingers who have broader agendas, such as opposition to abortion and support for the Jan. 6 insurrection, including Greene and the Proud Boys .

Her lawyers include San Francisco attorney Harmeet Dhillon, a veteran courthouse culture warrior who has brought lawsuits promoting gun rights, upholding voting restrictions, and opposing mask mandates. In January, Dhillon ran unsuccessfully for the chairmanship of the Republican National Committee.

Cole's legal complaint bears all the shortcomings common to initial filings in cases dealing with controversial topics, plus a few all its own. (I reached out to Cole via her lawyers but received no response.)

Her narrative is peopled with physicians and psychologists heartlessly and casually breaching their professional responsibilities. She says Kaiser and its professionals "blindly ramrodded" her into gender-affirming treatment. Kaiser, she alleges, deprived her and her parents of the knowledge they needed to give informed consent to what she describes as hasty life-altering decisions.

Cole's legal complaint incorporates what seem to be misleading or inaccurate descriptions of developments in the gender dysphoria treatment field.

The complaint states that "negative results" from the use of puberty blockers and hormones "caused" the shutdowns of a transgender clinic at Johns Hopkins Hospital in 1979 and Britain's Tavistock Gender Identity Development Service more recently.

Neither assertion is quite accurate.

The Johns Hopkins clinic was closed by the hospital's chief of psychiatry, Paul R. McHugh, on ideological and religious grounds; a devout Catholic, McHugh opposed gender reassignment treatments in principle and maintained, as he put it in a 2016 Wall Street Journal opinion piece , that "'sex change' is biologically impossible." Johns Hopkins shed McHugh's four-decades-old judgments and reestablished its gender identity clinic in 2017.

Tavistock has not been shut down, though it is slated for closure by Britain's National Health Service later this year. Its problems were not related to the medical issues with the treatments themselves, but rather with its being overwhemed, as Britain's lone treatment center, by a torrent of new gender dysphoria cases. The NHS plans to replace Tavistock with several regional centers to improve access for all such patients.

Cole's complaint also describes the conclusion of a 2011 Swedish study it cites as having found that "transition treatment does not improve long-term mental health for transgender individuals."

That's not what the study concluded, however. The study compared the mental and physical health of 324 patients who underwent gender reassignment surgery between 1973 and 2003 to the health of a control group of non-transgender individuals — not to transgender persons who had not undergone surgery.

"No inferences can be drawn as to the effectiveness of sex reassignment as a treatment," the study's authors cautioned. "Things might have been even worse without sex reassignment."

That doesn't surprise Baker and other transgender advocates. "Experiences of discrimination, harassment, violence, rejection get under the skin," Baker says.

"It is very hard to be transgender in a transphobic society. When you see high rates of depression and anxiety among transgender adults, that's the reason."

This story originally appeared in Los Angeles Times .

Column: California’s transgender sanctuary law survives a challenge as judge ridicules plaintiff’s claims

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In 2022, when legislation outlawing gender-affirming medical treatments erupted in mostly red-state legislatures across the land, California enacted a law creating a sanctuary for those whose treatments were blocked by the lawmakers.

SB 107, which was signed into law by Gov. Gavin Newsom that September, provided a safe harbor for people from those states who sought the treatment in California, where it’s legal.

The law prohibited the release of medical information about a patient if it was sought from a state that made the treatments illegal, and forbade the arrest or extradition of medical providers in California if the request came from authorities in states that had criminalized the treatments.

Our Watch firmly believes that transgenderism is a cultural issue that it must deal with in accordance with God’s design for every child, as outlined in the Bible.

— Our Watch vs. Bonta

Unsurprisingly, SB 107 became the target of right-wing, anti-LGBTQ+ activists in California. On Tuesday, federal Judge Dale A. Drozd of Sacramento dismissed an effort to declare the law unconstitutional .

It was the third attempt by the plaintiff, a nonprofit affiliated with a conservative Christian church in Temecula that says its mission is to “restore Christian-Judeo values in government and education,” to win Drozd’s approval for its lawsuit. This time, Drozd, plainly fed up with the plaintiff’s serial inability to make its case, forbade it to try again because any further filing would be, as he wrote, “futile under the circumstances.”

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Whether Drozd’s ruling will hold up under any appeal or whether the law itself can survive any other lawsuits to overturn it is impossible to say. But the lawsuit filed last year by the nonprofit Our Watch with Tim Thompson (he’s the pastor of the Temecula church) is nevertheless instructive. Our Watch was represented in court by lawyers affiliated with Advocates for Faith and Freedom , a Murrieta organization that lists “parental rights” and “the rights of children, both born and unborn,” among its concerns.

The lawsuit opens a window on the lengths to which zealots and fanatics will go to interfere with the activities of others because they conflict with their own narrow ideologies. There’s a polite name for them: “busybodies.”

The case also underscores how our personal rights are perched on a judicial knife edge in today’s America. There’s ample reason to believe that if such a case were to land in front of a Trump-appointed judge — U.S. Judge Matthew Kaczmaryk of Amarillo, Texas , for instance — the law would have been invalidated in a heartbeat. Appeal would have been taken to the Trump-infested 5th Circuit Court of Appeals, and perhaps ultimately to the Supreme Court, where its fate might be sealed.

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After all, that’s been the arc of Kaczmaryk’s ruling invalidating the Food and Drug Administration’s approval of the abortion drug mifepristone . In that case, Kaczmaryk and the 5th Circuit judges bought into the plaintiffs’ fanciful assertions that, as doctors, the prospect of medication abortions caused them “mental and emotional stress”; appeals judge James C. Ho rationalized upholding Kaczmaryk’s mifepristone ban by commenting, “Doctors delight in working with their unborn patients — and experience an aesthetic injury when they are aborted.”

That didn’t happen here because Drozd, an Obama appointee, can recognize a factitious claim for standing when it swims into his ken .

I’ve written before that transgender individuals have become the prime targets for discriminatory legislation in part because socially acceptable targets for hate-mongering and prejudice have become harder for conservative culture warriors to find.

As I observed in 2018 , open racism is out (though it made a strong comeback in the Trump era and in the hands of commentators such as Tucker Carlson ). In an increasingly pluralistic society, legislators who denigrated ethnic or religious minorities or those with mental illnesses or disabilities found themselves on the outs.

Gay and lesbian Americans have moved into the cultural and social mainstream. Many conservative families have found themselves embracing gay and lesbian siblings, children and parents as worthy of familial love and respect. Same-sex marriage has become embedded in the entertainment mainstream , portrayed on popular TV programs without apology.

Moreover, gay and lesbian people acquired a voice in the highest echelons of political power; gay-bashing no longer works for a political candidate as it has in the past, except perhaps in the most benighted corners of American society.

That leaves gender transition, which is easily caricatured and demonized by unscrupulous politicians aiming to rally their base against a wholly imaginary crisis. By early 2022, according to Human Rights Watch, 130 bills had been introduced in state legislatures. Many barred transgender youths from playing on sports teams or using bathrooms other than those designated for their birth gender.

As of this year, 23 states have banned or restricted gender-affirming treatments for youths ; some carry prison terms for violations or restrict insurance coverage. In Florida parents who allow such treatments for their children can lose custody; in Texas, they can be investigated for child abuse . Florida, Ohio and Missouri have implemented restrictions even on gender transition treatments for adults. A Florida rule barring Medicaid coverage for gender treatments was blocked by a federal judge, whose ruling is currently under appeal .

This is the environment that prompted California to enact its sanctuary law. Its law resembled the state’s effort to become a sanctuary for women seeking abortions that their home states had rendered illegal in the wake of the Supreme Court’s overturning of Roe vs. Wade in 2022.

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The plaintiff in this case left no question that its action was grounded in fundamentalist anti-transgender bias. “Our Watch firmly believes that transgenderism is a cultural issue that it must deal with in accordance with God’s design for every child, as outlined in the Bible,” the lawsuit says.

As so often occurs, the plaintiff’s case against the California law is a melange of misdirection and misrepresentations.

Our Watch positioned its lawsuit as an effort to protect the right “of parents to raise their children” without governmental interference. It depicted SB 107 as a law that “allows minors to obtain gender transition procedures like harmful puberty blockers, cross-sex hormones, and irreversible surgeries without parental consent, while denying parents access to their child’s medical information.”

This is a flatly inaccurate characterization of the law. It also turns the law’s goal on its head.

The truth is, as Atty. Gen. Rob Bonta observed in his response to the lawsuit , California law gives parents the right to access their children’s medical records. “Nothing in SB 107 changes that,” he noted. Further, he wrote, all those procedures listed in the lawsuit “generally require parental consent in California” — another regulation unaffected by SB 107.

The whole purpose of the California law, Bonta wrote, was to give parents of children seeking gender-affirming care refuge from out-of-state laws that interfered with their right to obtain medically indicated care for their children — not to allow such care over parents’ objections.

The lawsuit painted a picture of physicians willy-nilly imposing radical, irreversible gender-affirming treatments on innocent adolescents whose “gender dysphoria” (the medical term for gender uncertainties) might be transient and resolve themselves over time or with counseling.

That’s a caricature of the standard of care for gender dysphoria as it’s implemented by physicians following established protocols. The truth is that “prior to the onset of puberty, kids typically receive non-medical care,” explained Boston University psychologist Melissa K. Holt during a roundtable discussion of care for youths in 2022.

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Care for prepubescent children, Holt said, “is focused around social transitioning,” such as choosing a new name and adopting different dress, “and providing mental health and structural support, like schools using a child’s preferred gender pronouns and allowing them to use the bathroom that aligns with their gender identity.... There are no 4-year-olds going through irreversible medical procedures.”

Drugs such as puberty blockers and hormone treatments are typically administered only as children move into adolescence, are viewed as safe, and are expected to be used only after discussions with medical providers. Medical protocols discourage gender reassignment surgery before the age of 18. But professionals in the field say that outlawing such treatments or even counseling for younger children can produce long-standing psychological problems.

Much of the lawsuit’s argument was self-refuting. “Parents, not the government, are best suited to decide” on their child’s medical treatment, the lawsuit says. Exactly; so how do SB 107’s opponents explain state laws that allow the government to impose its judgment over the parents? The lawsuit is silent on that question.

In dismissing the case, Drozd didn’t address those issues, because he found that the lawsuit had a more fundamental shortcoming: The plaintiff didn’t have standing to bring the case at all.

“Standing” is a concept derived from the U.S. Constitution, which holds, roughly, that litigants in federal court must show that they’re directly harmed by a government action and that their lawsuit will remedy the injury. Our Watch couldn’t meet that requirement, Drozd ruled.

Our Watch claimed that it was “directly harmed” by SB 107 because the law prompted it to “divert our attention to transgender issues” rather than “tackling major cultural issues that violate Christian-Judeo values, including the sexual indoctrination of children, ... critical race theory, and abortion.” (Not to be churlish, but some people might be relieved that SB 107 narrowed the organization’s involvement in such overheated culture wars.)

Our Watch “plans to expend money on conferences to connect key stakeholders who are also fighting against the devastating effects of SB 107,” the lawsuit stated.

It wasn’t hard for the judge to see through this argument. Plaintiffs can’t “manufacture standing” through their own choices, he ruled: Our Watch’s “decision to place more focus and correspondingly commit more of its resources to ‘transgender issues’ ... was a voluntary decision — not a forced one.”

The culture wars over gender issues are sure to continue because they rely on public ignorance and prejudice — always the preferred weaponry of demagogues. The lawsuit to overturn California’s sanctuary law had, at its core, nothing to do with protecting children. If it did, its promoters wouldn’t have had to gin up a cause of action where none existed.

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Pulitzer Prize-winning journalist Michael Hiltzik has written for the Los Angeles Times for more than 40 years. His business column appears in print every Sunday and Wednesday, and occasionally on other days. Hiltzik and colleague Chuck Philips shared the 1999 Pulitzer Prize for articles exposing corruption in the entertainment industry. His seventh book, “Iron Empires: Robber Barons, Railroads, and the Making of Modern America,” was published in 2020. His forthcoming book, “The Golden State,” is a history of California. Follow him on Twitter at twitter.com/hiltzikm and on Facebook at facebook.com/hiltzik.

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Vatican calls gender fluidity and surrogacy threats to human dignity

Infinite Dignity declaration reaffirms church’s position on gender reassignment, abortion and euthanasia

The Vatican has described the belief in gender fluidity as “a concession to the age-old temptation to make oneself God”, as it released an updated declaration of what the Catholic church regards as threats to human dignity.

The new Dignitas infinita (Infinite Dignity) declaration released by the Vatican’s doctrinal office on Monday after five years in the making reiterates Pope Francis’s previous criticism of what he has called an “ugly ideology of our time”.

“Desiring a personal self-determination, as gender theory prescribes, apart from this fundamental truth that human life is a gift, amounts to a concession to the age-old temptation to make oneself God, entering into competition with the true God of love revealed to us in the gospel,” the 20-page document says.

Reiterating opposition to gender reassignment surgery, it adds: “It follows that any sex-change intervention, as a rule, risks threatening the unique dignity the person has received from the moment of conception.”

The Holy See distinguished between these sorts of surgeries and procedures to resolve “genital abnormalities” that are present at birth or develop later. It said those abnormalities could be treated with the help of healthcare professionals.

The Vatican said Pope Francis had approved the document, which also reaffirms its condemnation of surrogacy, saying the practice represents “a grave violation of the dignity of the woman and the child”.

“A child is always a gift and never the basis of a commercial contract,” the document says. “Every human life, beginning with that of the unborn child in its mother’s womb, cannot be suppressed, nor become an object of commodity.”

The chief cardinal, Victor Manuel Fernández, said on Monday that the pope had asked for the Vatican’s doctrinal office (DDF) to include “poverty, the situation of migrants, violence against women, human trafficking, war and other themes” in its updated assessment of threats to human dignity.

The document says gay people should be respected and denounces the fact that “in some places not a few people are imprisoned, tortured, and even deprived of the good of life solely because of their sexual orientation”.

Fernández, a liberal theologian who was appointed to the DDF role – one of the Vatican’s most powerful positions – by Francis last year, said punishing homosexuality was “a big problem” and that it was “painful” to see some Catholics support anti-homosexuality laws.

The declaration also reaffirms the church’s position on abortion and euthanasia while strongly condemning femicide. “Violence against women is a global scandal, which is increasingly being recognised,” it says.

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Vatican says sex reassignment surgery, surrogacy and gender theory threaten human 'dignity'

The Vatican has declared gender confirmation operations and surrogacy as grave threats to human "dignity", putting them on par with abortion and euthanasia as practices that violate God's plan for human life.

The Vatican's doctrine office on Monday published a 20-page declaration titled Infinite Dignity that was in the works for the past five years.

It was approved for publication by Pope Francis on March 25 after substantial revision in recent months.

In its most eagerly anticipated section, the Vatican reiterated its rejection of "gender theory" or the idea that one's gender can be "a self-determination".

It said God created man and woman as biologically different, separate beings, and said they must not tinker with that plan or try to "make oneself God".

"It follows that any sex-change intervention, as a rule, risks threatening the unique dignity the person has received from the moment of conception," the document said.

It distinguished between transitioning surgeries, which it rejected, and "genital abnormalities" that are present at birth or that develop later. Those abnormalities can be "resolved" with the help of health care professionals, it said.

The document's existence, rumoured since 2019, was confirmed in recent weeks by the new prefect of the Dicastery for the Doctrine of the Faith, Argentine Cardinal Víctor Manuel Fernández, a close confidante of Pope Francis.

He had cast it as something of a nod to conservatives after he authored a more explosive document approving blessings for same-sex couples that sparked criticism from conservative bishops around the world, especially in Africa.

While the new document rejected gender theory, it took pointed aim at countries — including many in Africa — that criminalise homosexuality.

It echoed Pope Francis's assertion in a 2023 interview that "being homosexual is not a crime", making the assertion now part of the Vatican's doctrinal teaching.

It denounced "as contrary to human dignity the fact that, in some places, not a few people are imprisoned, tortured, and even deprived of the good of life solely because of their sexual orientation".

The document restated well-known Catholic doctrine opposing abortion and euthanasia.

It also added to the list some of Pope Francis's main concerns as pope: the threats to human dignity posed by poverty, war, human trafficking and forced migration.

A child's right to 'a fully human origin'

In a newly articulated position, the declaration said surrogacy violated both the dignity of the surrogate mother and the child.

While much attention on surrogacy has focused on possible exploitation of poor women as surrogates, the Vatican document focuses more on the resulting child.

"The child has the right to have a fully human (and not artificially induced) origin and to receive the gift of a life that manifests both the dignity of the giver and that of the receiver," the document said.

"Considering this, the legitimate desire to have a child cannot be transformed into a 'right to a child' that fails to respect the dignity of that child as the recipient of the gift of life."

The Vatican published its most articulated position on gender in 2019, when the Congregation for Catholic Education rejected the idea that people can choose or change their genders.

It insisted on the complementary nature of biologically male and female sex organs to create new life.

Gender fluidity was described as a symptom of the "confused concept of freedom" and "momentary desires" that characterise post-modern culture.

The new document from the more authoritative Dicastery for the Doctrine of the Faith quoted from that 2019 education document but tempered the tone.

Significantly, it did not repurpose the 1986 language of a previous doctrinal document saying that homosexual people deserve to be treated with dignity and respect but that homosexual actions are "intrinsically disordered".

Francis has made reaching out to LGBTQ+ people a hallmark of his papacy, ministering to trans Catholics and insisting that the Catholic Church must welcome all children of God.

But he has also denounced "gender theory" as the "worst danger" facing humanity today, describing it as an "ugly ideology" that threatens to cancel out God-given differences between man and woman.

"It needs to be emphasised that biological sex and the sociocultural role of sex (gender) can be distinguished but not separated," the new document said.

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Vatican Document Casts Gender Change and Fluidity as Threat to Human Dignity

The statement is likely to be embraced by conservatives and stir consternation among L.G.B.T.Q. advocates who fear it will be used as a cudgel against transgender people.

By Jason Horowitz and Elisabetta Povoledo

Reporting from Rome

The Vatican on Monday issued a new document approved by Pope Francis stating that the church believes that gender fluidity and transition surgery, as well as surrogacy, amount to affronts to human dignity.

The sex a person is assigned at birth, the document argued, was an “irrevocable gift” from God and “any sex-change intervention, as a rule, risks threatening the unique dignity the person has received from the moment of conception.” People who desire “a personal self-determination, as gender theory prescribes,” risk succumbing “to the age-old temptation to make oneself God.”

Regarding surrogacy, the document unequivocally stated the Roman Catholic Church’s opposition, whether the woman carrying a baby “is coerced into it or chooses to subject herself to it freely.” Surrogacy makes the child “a mere means subservient to the arbitrary gain or desire of others,” the Vatican said in the document, which also opposed in vitro fertilization.

The document was intended as a broad statement of the church’s view on human dignity, including the exploitation of the poor, migrants, women and vulnerable people. The Vatican acknowledged that it was touching on difficult issues, but said that in a time of great tumult, it was essential, and it hoped beneficial, for the church to restate its teachings on the centrality of human dignity.

Even if the church’s teachings on culture war issues that Francis has largely avoided are not necessarily new, their consolidation now was likely to be embraced by conservatives for their hard line against liberal ideas on gender and surrogacy.

The document, five years in the making, immediately generated deep consternation among advocates for L.G.B.T.Q. rights in the church, who fear it will be used against transgender people. That was so, they said, even as the document warned of “unjust discrimination” in countries where transgender people are imprisoned or face aggression, violence and sometimes death.

“The Vatican is again supporting and propagating ideas that lead to real physical harm to transgender, nonbinary and other L.G.B.T.Q.+ people,” said Francis DeBernardo, the executive director of New Ways Ministry, a Maryland-based group that advocates for gay Catholics, adding that the Vatican’s defense of human dignity excluded “the segment of the human population who are transgender, nonbinary or gender nonconforming.”

He said it presented an outdated theology based on physical appearance alone and was blind to “the growing reality that a person’s gender includes the psychological, social and spiritual aspects naturally present in their lives.”

The document, he said, showed a “stunning lack of awareness of the actual lives of transgender and nonbinary people.” Its authors ignored the transgender people who shared their experiences with the church, Mr. DeBernardo said, “cavalierly,” and incorrectly, dismissing them as a purely Western phenomenon.

Though the document is a clear setback for L.G.B.T.Q. people and their supporters, the Vatican took pains to strike a balance between protecting personal human dignity and clearly stating church teaching, a tightrope Francis has tried to walk in his more than 11 years as pope.

Francis has made it a hallmark of his papacy to meet with gay and transgender Catholics and has made it his mission to broadcast a message for a more open, and less judgmental, church. Just months ago, Francis upset more conservative corners of his church by explicitly allowing L.G.B.T.Q. Catholics to receive blessings from priests and by allowing transgender people to be baptized and act as godparents .

But he has refused to budge on the church rules and doctrine that many gay and transgender Catholics feel have alienated them, revealing the limits of his push for inclusivity.

“In terms of pastoral consequences,” Cardinal Víctor Manuel Fernández, who leads the Vatican’s office on doctrine, said in a news conference Monday, “the principle of welcoming all is clear in the words of Pope Francis.”

Francis, he said, has repeatedly said that “all, all, all” must be welcomed. “Even those who don’t agree with what the church teaches and who make different choices from those that the church says in its doctrine, must be welcomed,” he said, including “those who think differently on these themes of sexuality.”

But Francis’ words were one thing, and church doctrine another, Cardinal Fernández made clear, drawing a distinction between the document, which he said was of high doctrinal importance, as opposed to the recent statement allowing blessings for same-sex Catholics. The church teaches that “homosexual acts are intrinsically disordered.”

In an echo of the tension between the substance of church law and Francis’ style of a papal inclusivity, Cardinal Fernández said on Monday that perhaps the “intrinsically disordered” language should be modified to better reflect that the church’s message that homosexual acts could not produce life.

“It’s a very strong expression and it requires explanation,” he said. “Maybe we could find an expression that is even clearer to understand what we want to say.”

Though receptive to gay and transgender followers, the pope has also consistently expressed concern about what he calls “ideological colonization,” the notion that wealthy nations arrogantly impose views — whether on gender or surrogacy — on people and religious traditions that do not necessarily agree with them. The document said “gender theory plays a central role” in that vision and that its “scientific coherence is the subject of considerable debate among experts.”

Using “on the one hand” and “on the other hand,” language, the Vatican’s office on teaching and doctrine wrote that “it should be denounced as contrary to human dignity the fact that, in some places, not a few people are imprisoned, tortured, and even deprived of the good of life solely because of their sexual orientation.”

“At the same time,” it continued, “the church highlights the definite critical issues present in gender theory.”

On Monday, Cardinal Fernández also struggled to reconcile the two seemingly dissonant views.

“I am shocked having read a text from some Catholics who said, ‘Bless this military government of our country that created these laws against homosexuals,’” Cardinal Fernández said on Monday. “I wanted to die reading that.”

But he went on to say that the Vatican document was itself not a call for decriminalization, but an affirmation of what the church believed. “We shall see the consequences,” he said, adding that the church would then see how to respond.

In his presentation, Cardinal Fernández described the long process of the drafting of a document on human dignity, “Infinite Dignity,” which began in March 2019, to take into account the “latest developments on the subject in academia and the ambivalent ways in which the concept is understood today.”

In 2023, Francis sent the document back with instructions to “highlight topics closely connected to the theme of dignity, such as poverty, the situation of migrants, violence against women, human trafficking, war, and other themes.” Francis signed off on the document on March 25.

The long road, Cardinal Fernández wrote, “reflects the gravity” of the process.

In the document, the Vatican embraced the “clear progress in understanding human dignity,” pointing to the “desire to eradicate racism, slavery, and the marginalization of women, children, the sick, and people with disabilities.”

But it said the church also sees “grave violations of that dignity,” including abortion, euthanasia, the death penalty, polygamy, torture, the exploitation of the poor and migrants, human trafficking and sex abuse, violence against women, capitalism’s inequality and terrorism.

The document expressed concern that eliminating sexual differences would undercut the family, and that a response “to what are at times understandable aspirations,” will become an absolute truth and ideology, and change how children are raised.

The document argued that changing sex put individualism before nature and that human dignity as a subject was often hijacked to “justify an arbitrary proliferation of new rights,” as if “the ability to express and realize every individual preference or subjective desire should be guaranteed.”

Cardinal Fernández on Monday said that a couple desperate to have a child should turn to adoption, rather than surrogacy or in vitro fertilization because those practices, he said, eroded human dignity writ large.

Individualistic thinking, the document argues, subjugates the universality of dignity to individual standards, concerned with “psycho-physical well-being” or “individual arbitrariness or social recognition.” By making dignity subjective, the Vatican argues, it becomes subject to “arbitrariness and power interests.”

Jason Horowitz is the Rome bureau chief for The Times, covering Italy, the Vatican, Greece and other parts of Southern Europe. More about Jason Horowitz

Elisabetta Povoledo is a reporter based in Rome, covering Italy, the Vatican and the culture of the region. She has been a journalist for 35 years. More about Elisabetta Povoledo

Hong Kong Amends Its Surgery Requirements to Change Gender Markers on IDs

H ong Kong no longer requires transgender people to undergo full gender-affirming surgery to change their legal gender markers in their IDs, more than a year after the Chinese enclave’s top court called the requirement unconstitutional.

The government announced the change on Wednesday, “having prudently considered the objective of the policy, relevant legal and medical advice, as well as drawing reference from the relevant practices overseas.”

Under the new rules, Hong Kong residents who have not undergone full sex reassignment surgery [SRS] who want to have their gender marker on their ID changed still must have completed select surgical treatment to modify their sexual characteristics—removal of the breasts for transgender men, removal of the penis and testes for transgender women—along with medical documentation. Previous guidelines required the removal of the uterus and ovaries or the construction of a penis or “some form” of it for female-to-male transition, and the removal of the penis and testes and the construction of a vagina for male-to-female transition.

“We are still concerned about the heavy emphasis on sex reassignment surgeries being a requirement,” Wong Hiu-chong, the lawyer for transgender activist Henry Tse , whose case led to the policy change, told TIME. “SRS can be life threatening.”

Those who wish to change their gender markers must also statutorily declare that they have gender dysphoria—the medical term for the psychological distress a person feels when their gender identity does not match with their assigned sex at birth—and have lived as the opposite sex for at least two years before their application. They must also show proof of receiving hormonal treatment throughout the previous two years, and will be subjected to random blood tests to check their hormonal profile.

“Our clients have waited a very long time for such an unconstitutional policy to be revised, and for them, the wait has been painful,” Wong said in a statement. She also questioned the need for blood tests, calling this requirement, among others that remain for gender marker changes, “potentially discriminatory” as it does not apply to other Hong Kong ID card holders.

A government spokesperson clarified in the announcement that the gender marker change will only apply to the Hong Kong Identity Card and that “the sex entry on a Hong Kong identity card does not represent the holder’s sex as a matter of law. It does not affect any other policies of the Government or the handling of any other gender-related matters under the law in Hong Kong or relevant legal procedures.”

The policy change comes years after Tse filed a case in 2017 to question the full gender-affirming surgery requirement. Despite the city’s Court of Final Appeal issuing a ruling deeming the requirement unconstitutional in February 2023, implementation of the ruling was long-delayed, which Tse also challenged . The ruling said “such surgical procedures are at the most invasive end of the treatment spectrum” and that “full SRS is not medically required by many transgender persons whose gender dysphoria has been effectively treated.”

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