Religious Attitudes Toward

Gender-Confirming Surgery
22
Leonard A. Sharzer, David A. Jones,
Mehrdad Alipour, and Kelsey Jacob Pacha

 rotestant and Other Christian

P This section explores the sources mainline
Responses to Gender Transition Protestant denominations use to affirm people
who undergo gender confirmation surgery, exam-
Kelsey Jacob Pacha ines three theological problems for Protestant
Christians who condemn gender confirmation
Protestant Christianity encompasses over 10,000 surgery, briefly discusses other Christian tradi-
denominations, from the socially progressive tions (i.e., Jehovah’s Witnesses and Mormons),
United Church of Christ to the conservative considers possible impacts of these theologies on
Southern Baptist Convention. Approximately half patients and their families, and, finally, offers rec-
of all Americans identify as Protestant; however, ommendations for medical professionals. It is
there is no single typical Protestant response to important to note that where statements on gen-
surgical gender transition.1, 2 Protestant Christians der confirmation surgery have been issued by
tend to rely on the Bible and their individual Protestant groups, they are almost exclusively
relationships with God to inform their ethical
­ focused on genital surgery, with little mention of
­perspectives. Theological stances ostensibly per- non-genital procedures (chest reconstruction, tra-
taining to transgender and gender-diverse people cheal shaves, etc.)
vary from extremely condemnatory to extremely
celebratory.
 ainline Protestants and Resources
M
Jones and Cox [1, pp. 10–11].
1  for Affirmation
Pew Research Center [2, p. 3].
2 

Almost every mainline Protestant denomination

L. A. Sharzer (*)
Finkelstein Institute for Religious and Social Studies, (including the Episcopal, Lutheran, Methodist,
The Jewish Theological Seminary, and Presbyterian churches) affirms and accepts
New York, NY, USA transgender and gender-diverse people and their
e-mail: lesharzer@jtsa.edu
right to participate in the life of their faith com-
D. A. Jones munity after undergoing gender confirmation
St. Mary’s University, Twickenham, UK
surgery.3 These churches draw on a number of
M. Alipour sources within their traditions to support surgical
Institute of Arab and Islamic Studies, Exeter, UK
transition, including Biblical and historical
K. J. Pacha gender-­transgressive figures in Christianity, the-
Master of Divinity and Master of Arts in Religion
and Psychology, Pacific School of Religion,
Berkeley, CA, USA Markham and Wolf [4].
3 

© Springer Nature Switzerland AG 2020 225

L. S. Schechter (ed.), Gender Confirmation Surgery, https://doi.org/10.1007/978-3-030-29093-1_22
226
ologies that see creation as an ongoing process,
and by privileging an individual’s personal rela-
tionship with God over doctrine.
Biblical and historical figures. Many trans-
gender Christians and theologians point to gen-
der non-conforming figures of scripture and
church history as so-called “trans-cestors,” or
gender-transgressive ancestors. These can
include people who defied gender norms of their
era as well as eunuchs. Strong women like
Deborah and Queen Esther are considered gender
non-conforming as they took on roles tradition-
ally reserved for men, like being a judge or mili-
tary leader. Some point to more subtle figures,
such as the man carrying water that Jesus tells his
disciples to follow to the Upper Room for the
Last Supper (Mark 14:13, Luke 22:104). At the
time, water carrying was a task only done by
women, a reality affirmed by the many Gospel
stories where Jesus interacts with women near
wells.5 Some scholars indicate that even Paul ref-
erenced the wisdom of a gender non-conforming
poet, Epimenides, in the book of Titus, calling
him a “prophet…whose witness is true.”6
Eunuchs, castrated male consorts of the
ancient Near East, play an incredibly important
role in both the Hebrew Bible and New Testament.
Eunuchs are considered a third gender, occupy-
ing neither male nor female space. Although the
Holiness Code of Deuteronomy prohibits men
“whose testicles have been cut or crushed” from
entering assemblies of worship (Deut 23:1), the
prophet Isaiah makes it clear that eunuchs who
love God will be welcomed in the kingdom
despite the law’s exclusion of them (Is 56:3–8).
Significantly, the first Christian convert in Acts 8
was an Ethiopian eunuch, marginalized by both
race and gender.
Jesus himself promises hope to eunuchs in
Matthew 19:12, saying “For there are eunuchs
who have been so from birth, and there are
eunuchs who have been made eunuchs by others,
and there are eunuchs who have made them-
All Bible passages are from the New Revised Standard
4 
Version (NRSV) translation.
5 
Payne [5, p. 89].
6 
Mollenkott and Sheridan [6, p. 149].
L. A. Sharzer et al.
selves eunuchs for the kingdom of heaven.”
Virginia Ramey Mollenkott contends that Jesus
is lauding the unique gifts of gender-transgres-
sive people. She believes the first group includes
intersex people, the second group includes “post-
operative transsexuals,” and the third group
includes “not only pre-operative and non-opera-
tive transsexuals but all other transgenderists
[i.e., non-binary individuals, cross-dressers, drag
performers, etc.].”7
Finally, Christian history boasts many gender-­
transgressive figures considered paragons of
faith, the most prominent being Saint Joan of
Arc. There are several medieval legends of the
so-called “transgender saints,” such as St.
Pelagia/Pelagius or St. Wilgefortis, assigned
female at birth, who prayed to become male so
they could devote their lives to God in monaster-
ies and avoid marriage. Even effeminate Pope
Paul II is considered a gender transgressor.8
Creation as an ongoing process. Some
Protestant Christians believe “God is still speak-
ing,” and that God’s revelation did not just hap-
pen in the past but happens in the present as well.
They reject the notion that God intended only one
kind of gender or sexual expression for humanity
and see the flourishing of different gender identi-
ties and even advancements in surgical transition
as God’s way of revealing something new about
God. Transmale pastor and scholar Justin Tanis
writes, “Through trans and intersexed bodies,
God reveals Godself to be a Creator who loves
diversity and variation, a Creator who improvises
and varies the melodies that call each person into
being.”9 God’s intention for humanity did not
stop with the creation stories of Genesis 1 and 2,
but continues through each individual’s journey.
Some transgender and gender-diverse people
see suppressing their gender identity (or gender
creativity, as the case may be) as rejecting God’s
intention for their life, and thus pursuing medical
interventions that allow them to feel comfortable
and authentic is the most ethical way for them to
proceed. Transwoman Sheryl Stewart com-
7 
Mollenkott [7, p. 136].
8 
Mollenkott [7, p. 130–31].
Tanis [8, p. 166].
9 
22  Religious Attitudes Toward Gender-Confirming Surgery
mented, “Pretending to be a man, in obedience to
my body, was a temptation to deny the creative
act of God in making my spirit female. Of course,
SRS [sic] is not as simple as “cutting something
off and throwing it away.” This is not simply a
subtractive procedure but involves creation as
well.”10
Justification by faith and an individual
relationship with God. Many transgender and
gender-­diverse Christians and affirming denomi-
nations rely on the Protestant idea of “justi-
fication by faith” to substantiate acceptance
of TGNC people. Justification by faith privi-
leges an individual’s acceptance of Christ over
any outward works or recognition by a church
designed to prove one is going to heaven. Many
people feel their gender journeys are divinely
ordained by God. Responding to the call to
transform one’s gender has been described by
some TGNC Christians as a vocation, similar
to a call to ministry,11 and as an act of faith.12
Ashley Moore, a transfemale Christian minister
and founder of the world’s first all-transgender
gospel choir, has said: “[Transgender] persons
seem to be an acutely spiritual people. Perhaps
this is because once you reach the point of say-
ing that who you are transcends your physical
form, then you are immediately aware of your-
self as a spiritual being.”13
Non-affirming Perspectives: Three
Theological Problems
From a non-affirming Protestant perspective,
there are (broadly) three theological problems
related to gender affirmation surgery. These are as
follows: (1) Gender confirmation surgery threat-
ens God’s sovereignty by challenging notions of
a natural and divinely ordained gender binary. (2)
It invokes controversies about the relationship
between the body and the soul. (3) It encourages
10 
Stewart [9, p. 86].
Tanis, Trans-Gendered: Theology, Ministry, and
11 
Communities of Faith, 147.
12 
Mollenkott and Sheridan, Transgender Journeys, 123.
13 
Moore [10, p. 110].
227
a non-heteronormative and ­non-­procreative use
of one’s sexuality. Each of these ideas will be
discussed, along with its context.
(1) Gender confirmation surgery threatens God’s
sovereignty by challenging notions of a natu-
ral and divinely ordained gender binary.
Some Christians oppose gender confirma-
tion surgery as an affront to God’s power
and purpose for the human race. The Council
on Biblical Manhood and Womanhood
(CBMW), a group of evangelical leaders and
scholars, claims when transgender people
alter their body surgically, they are “denying
God his rightful place as sovereign creator…
establish[ing] themselves as autonomous
lords.”14 People who undergo gender confir-
mation surgery are seen as resisting God’s
intention in creation and desecrating the
body God gave them.
These convictions rest on a theology that
interprets the creation stories of Genesis 1 and 2
as establishing two dimorphic sexes, comple-
mentary in their gender roles, for the purpose of
procreation in the context of a lifelong, hetero-
sexual partnership. This intention constitutes not
just a physical destiny, but also a spiritual destiny,
vital to the propagation of the human race.
Several conservative Christian groups, including
medical associations, have issued statements
claiming that biological sex and gender identity
are the same thing according to God.15,16
Biblical texts like 1 Timothy 2 reinforce the
idea of complementarity between men and
women, with men as the head of the household
and women as gently submitting to their hus-
bands’ authority. For traditions that reject “trans-
gender self-conceptions” as contrary to God’s
will for humanity, a pressing concern seems to be
Kline and Schrock [11].
14 
The Council on Biblical Manhood and Womanhood [12]
15 
“Nashville Statement: A Coalition for Biblical Sexuality”
(The Council on Biblical Manhood and Womanhood,
August 29, 2017), sec. 5, https://cbmw.org/nashville-
statement/.
Christian Medical and Dental Associations House of
16 
Representatives [13].
228 L. A. Sharzer et al.

the ways in which a trans identity problematizes the “divinely ordained purpose of sex.”18
these notions of a divinely ordered masculinity This criticism conflates gender identity and
and femininity. The CBMW warns that blurring sexuality by claiming one’s sex assigned at
lines between distinct gender roles will “lead to birth is still the “real” sex post-surgery. These
increasingly destructive consequences in our Christians believe gender confirmation sur-
families, our churches, and the culture at large.”17 gery facilitates and encourages “same sex”
sexual contact.
(2) Gender confirmation surgery invokes contro-
versies about the relationship between the
body and the soul. Christianity has wrestled Other Christian Traditions
with the question of the relationship between
the mind, body, and soul in various ways Other Christian traditions outside of mainline
throughout its history. Early church leaders Protestantism, including Christian Scientists,
struggled with a significant controversy over Jehovah’s Witnesses, Mormons (The Church of
whether new Christian converts should be Jesus Christ of Latter-Day Saints), and Seventh-­Day
circumcised and keep Jewish dietary laws, as Adventists have issued statements on gender confir-
most of the church leaders were formerly mation surgery, which will be briefly summarized.
Jewish. Early church leaders encouraged Christian Scientists: Christian Scientists rely
people to remain celibate, to fast, and to denyon prayer and faith healing rather than traditional
their bodies in order to keep their spiritual medical intervention to resolve physical ailments.
connections pure and prepare appropriately One of the central tenets of Christian Science is
for the second coming of Christ. Controversies the idea that humans are not material; they are
over how God was present in the humanity of only spiritual. Although the church has not issued
Jesus also caused serious conflict in the earlyan official statement on transgender people, it has
church. published both affirming and condemnatory arti-
cles on trans people in the Christian Science
Disagreements about the relationship between Monitor and Christian Science Sentinel.
the mind, body, and spirit are ultimately about Jehovah’s Witnesses: Jehovah’s Witnesses will
how individuals understand the sources of their not baptize someone who has had gender confir-
self-knowledge and distinguish between what is mation surgery unless that person lives as the sex
“real” and what is “not real.” Trans and gender-­ they were assigned at birth. Equating biological
diverse people engage this tension directly by sex with gender identity, they advise: “Mutilating
recognizing that their minds and/or spirits are not the sex organs, such as having the male organ sur-
congruent with their bodies. For this reason, the gically removed and an artificial female organ
moral evaluation of changing one’s body to fit created, does not change the facts or make the
one’s mind (and/or soul) is fraught with intense person into the opposite sex.”19
division among Protestant Christians, who dis- LDS Church (Mormon): Mormons believe
agree about the legitimacy of claims about one’s “Gender is an essential and eternal [emphasis
“true” gender. mine] characteristic of individual…identity
and purpose.”20 People who are considering
(3) Gender confirmation surgery encourages a
non-heteronormative and non-procreative
use of one’s sexuality. Some Christians are 18 Christian Medical and Dental Associations House of
opposed to gender confirmation surgery on Representatives, “Transgender Identification Ethics
Statement,” 1.
the grounds that it encourages sexual activity 19 
“Correspondence Guidelines” [15, p. 98].
that is non-procreative and thus opposed to 20 The First Presidency and Council of the Twelve Apostles
of the Church of Jesus Christ of Latter-Day Saints of The
Council on Biblical Manhood and Womanhood [14].
17 
Church of Jesus Christ of Latter-day Saints [16].
22  Religious Attitudes Toward Gender-Confirming Surgery
“an elective transsexual operation” cannot be
baptized, but people who have already under-
gone gender confirmation surgery may be
approved for baptism, pending the permission
of the governing body of the LDS church.
They may also not receive the priesthood (to
do ministry and teaching) and cannot receive a
temple recommend (and thus cannot partici-
pate in any ceremonies in the church). They
may also face formal church discipline.21
There is still confusion on the part of the
church on whether transgender children can be
welcomed. Dallin Oaks, an apostle of the
church, admitted they hadn’t worked out all of
the details of their trans policies. However,
some LDS families and communities indeed
affirm their transgender and gender-diverse
brethren who undergo surgery.22
Seventh-Day Adventists: The SDA church
“cautions” transgender people against gender
confirmation surgery on the grounds that “from a
Biblical perspective,” the body and soul are one
and that any incongruence between one’s biolog-
ical sex and gender identity is due to sin.23
Transgender people who undergo surgery and
have sexual relationships with others of the same
sex assigned at birth may not be members of the
church and are expected to remain celibate and
living as their gender assigned at birth.
Impacts on Patients and Families
There are a wide range of ways patients impacted
by Protestant Christianity may bring their former
or current beliefs into the medical transitioning
process. Some patients may want a faith leader,
healer, or other practitioner to be present before
or after surgery to pray or ritualize the event.
Others may harbor ambivalence about altering
their bodies to be congruent with their deeply
held gender identity, whether they are currently
part of a faith community or not. Still others may
The Church of Jesus Christ of Latter-Day Saints [17,
21 
p. 8].
Allen [18].
22 
23 
Seventh-Day Adventist World Church [19].
229
be pursuing surgery in defiance of their families’
or other caregivers’ religious beliefs, which may
become obvious during preparation for a
procedure.
Up until the day of the procedure, some
patients may have a mix of feelings toward the
impending changes—an urgency to transform
their body along with fear, guilt, or shame as a
result of their childhood religious beliefs. Sheryl
Stewart describes a prayer she said prior to her
own surgery: “God, I might be wrong about who
and what I am, but I HAVE to go there. Please
walk with me and make me the best woman I can
be, the one you wanted to create when you called
me into life.”24
Some patients may feel they are choosing sur-
gery over their families, faith communities, and
belief systems that condemn transition-related
surgery. One transman articulated the intensity of
this struggle between faith and identity congru-
ence as follows: “What is the bigger crime? To
alter my existence with suicide or my body in the
pursuit of contentment? Both are sins against
God and humanity, they tell me. If both are
wrong, which is the bigger evil?...For me, mascu-
linizing hormones and sexual reassignment sur-
gery (SRS) was the only option if I did not want
to die.”25
It is important to attend to cultural factors that
overlap with theology and church membership,
especially among people of color-led churches
where stark gender roles and involvement in faith
communities have historically insulated these
communities from white supremacy. Several
studies suggest that non-white trans and gender-­
diverse people negotiate their identities differ-
ently than white transgender and gender-diverse
people, often delaying or foregoing coming out
to family and friends, staying in non-affirming
faith communities, and upholding more tradi-
tional gender roles.26
Other patients may have ample support from
their religious families, spiritual leaders, and
faith communities. Some traditions even have
Stewart, “My Story,” 86.
24 
McDaniel [20, p. 21].
25 
CJBH Bauchman [22], McQueeney [23], Pitt [24].
26 
230 L. A. Sharzer et al.

prayers and rituals prepared to support individu-  eo-Pagan, New Age, and Eclectic
N
als as they pursue gender confirmation surgery. Spirituality: A Rising Trend
The book Transgendering Faith offers several
such resources, including the following prayer: A rising number of transgender and gender-­
diverse people are involved in spiritual communi-
God, these are instruments of your creativity— ties outside of the Judeo-Christian paradigm,
hormone injections, electrolysis, surgery, including earth-based, neo-Pagan, wiccan, and
new clothes and new names— new age communities. Although there has not
We dedicate them to your blessing. been a nationally representative study of trans-
gender people’s religious affiliations, preliminary
God, these are channels of your grace— evidence suggests LGB and transgender and
Dear friends, therapists, doctors, gender-­diverse people are more likely to be wic-
Family members—honest with hope or doubt— can/pagan28 and twice as likely as the general
And a community of open-hearted love…27 population to identify with a non-Judeo Christian
tradition.29 Reclaiming such traditions may be
related to the high rate of faith-based rejection
Recommendations for Surgeons TGNC people experience.30 Many transgender
and gender-diverse people may not belong to a
1. Take time to listen and discern how a patient’s faith community but regularly see an energy
or family’s spiritual beliefs may impact their healer (such as a reiki master), psychic, astrolo-
preparation for, approach to, and recovery ger, or herbalist to care for their mind-body con-
from surgery. For many transgender and nection and inform their transition-related
gender-­diverse people, entrusting their bodies decisions. Others may reclaim an indigenous tra-
to strangers feels very vulnerable and scary, dition or engage in ancestor worship or other
particularly when they have had negative expe- invocations.
riences with physicians previously. Many trans Some transgender and gender-diverse people
people experience the manipulation and evalu- may choose to use herbs, supplements, and/or
ation of their bodies as quite traumatic. It is nutrition to manage their transition (i.e., by
vital to make an effort to honor a patient’s attempting to raise their natural hormone levels).31
wishes related to creating safety and protection It is important to know what kinds of herbs and
using the spiritual resources available to them. supplements a patient might be using and how
2. Take seriously the ways in which a non-­ this may impact their ability to prepare for and

affirming family or faith community may neg- heal from surgery. Some patients may want to
atively affect a patient’s healing process. ritualize their procedure, take a protective herb
Remind patients and families that faith com- packet or crystal in with them to surgery, or
munities that welcome and celebrate trans- receive energy work before or after the proce-
gender and gender-diverse people who have dure. Some may even want to schedule their sur-
had surgery exist. gery according to auspicious dates according to
3. Have referrals available to trans-competent their astrological chart. Regardless of how famil-

and trans-affirming clinicians, faith leaders, iar a physician may be with such practices,
and other helping professionals who have respect for their choices within the context of
experience with religious and spiritual issues. optimizing health should be a priority.
Ensure each referral is trans-competent and
trans-affirming, and be wary of religious 28 Herek et al. [26, p. 189].
counselors that may practice conversion 29 Pew Research Center [27, p. 91].
therapy. James et al. [28].
30 

Examples of herbal protocols for TGNC people include:

31 

Tirabassi [25, p. 118].

27 
Dori Midnight [29], Sigler [30].
22  Religious Attitudes Toward Gender-Confirming Surgery
 atholic Positions Regarding
C degree of overlap between Christian attitudes to
Gender-Confirming Surgery
David A. Jones
A Diversity of Christian Views
Christian views of gender-confirming surgery
(GCS) vary. This is for at least three reasons: In the
first place, there are differences in approach
between different Christian denominations. A
broad and useful division, especially for
Christianity in the United States, is between
Evangelical Protestants (approximately 25% of
the population), Mainline Protestants (approxi-
mately 15%), and Catholics (approximately 20%).
In a healthcare context, the beliefs and practices of
the Catholic Church have an added practical and
political importance because of its role as a health-
care provider: one in six patients in the United
States is cared for in a Catholic hospital.
There are characteristic differences between
these three groups not only in the conclusions they
come to on moral or social issues, but also in how
they come to these conclusions – what they take as
sources of authority, and how they use these sources,
and in how decisions are made within the churches.
In the second place, within any religious group
or organization there will be differences between the
agreed, official or scholarly view and the view of
individual members of the group. This is evident, for
example, on a question such as termination of preg-
nancy where individual opinions can vary widely.
In the third place, there will be different
schools of thought among respected scholars and
among church leaders. This is typical of any
intellectual tradition. Some questions may be
straightforward, at least from an official perspec-
tive, but there will always be questions that are
less clear or questions on which there is no con-
sensus or authoritative ruling.
Gender Identity and Homosexuality
Though a person’s sense of gender identity is dis-
tinct from his or her sexual orientation, there is a
231
homosexuality and attitudes to gender dysphoria.
Mainline Protestant churches which have
accepted same-sex marriage and openly homo-
sexual clergy will typically seek also to affirm
people who identify as having a gender identity
incongruent with their sex assigned at birth. For
the same reason, members of these churches will
tend to look favorably on GCS where this is
desired by the person as affirming his, her, or
their experienced gender identity. It is also the
case that Mainline Protestant Christianity has not
developed a strong independent tradition of med-
ical ethics.
At an official level, Evangelical and Catholic
churches are opposed to same-sex marriage on
Biblical or doctrinal grounds. For similar rea-
sons, then, Evangelical and Catholic Christians
will tend to have concerns that transitioning to
another gender role is a failure to accept “the
God-given personhood that is manifest through
one’s sexuality.”32 For example, a recent position
statement by Evangelical Christians denies that
“adopting a homosexual or transgender self-­
conception is consistent with God’s holy
purposes”33 and states that it is “sinful to approve
of homosexual immorality or transgenderism.”34
As stated above, individual members of a
church will not always accept the official teach-
ing and, where an Evangelical or a Catholic
Christian supports same-sex marriage then he or
she is also likely to support gender transition and
gender confirmation surgery.
Catholic Moral Theology
and the Ethics of Sterilization
Quite apart from the analogy with homosexual-
ity, a further challenge to GCS from a Catholic
Stephens [31, p. 32].
32 
Council on Biblical Manhood and Womanhood
33 
(CBMW) “Nashville Statement on Biblical Sexuality”
(August 29, 2017) Article 7. https://cbmw.org/
nashville-statement/.
CBMW “Nashville Statement” Article 10. See also Daly
34 
[33], drawing on O’Donovan [34].
232
perspective relates to the destruction of biologi-
cal function. There is a long tradition of Catholic
reflection on the ethics of medicine and surgery,
predating by many centuries the recent rise of
biomedical ethics. The Catholic understanding of
medicine and surgery sees these practices as
“restoring the anatomical functional integrity of
the body of the human person and, through this,
his psyche or mind.”35 On this view, surgery that
involves destruction or compromise of the ana-
tomical functional integrity of some part of the
body, for example, the amputation of a limb, is
justified only where this is for the sake of the
functioning of the body as a whole. This princi-
ple, sometimes called “the principle of totality”36
is difficult to reconcile to forms of surgery that
cause immediate harm to biological function for
the sake of psychosocial or other indirect
benefits.
The principle of totality is affirmed, though
not using the same language, within the
Evangelical tradition. On a similar basis, the
Christian Medical and Dental Associations, the
largest organizations representing Evangelical
healthcare professionals, state that “Christian
physicians should not engage in hormonal and
surgical interventions that alter natural sex phe-
notypes, as this contradicts the basic principles of
Christian medical ethics, which regards medical
treatment as intended to heal and not to harm.”37
Within the Catholic tradition, perhaps the
most commonly cited form of surgery to be
rejected on the basis of the principle of totality is
“direct sterilization,” that is, sterilization for the
purpose of birth control. Direct sterilization
serves a social or personal end rather than a medi-
cal one. Even if pregnancy would cause medical
problems, sterilization does not immediately or
directly address the problems of pregnancy but
35 
Eijk [35, p. 209].
36 
Kelly [36]; Pope Pius XII, “Address to the First
International Congress on the Histopathology of the
Nervous System” (September 14, 1952).
37 
Christian Medical and Dental Associations,
“Transgender Identification Ethics Statement” (April 21,
2016), Recommendations for Christian Healthcare
Professionals, No. 3. https://www.cmda.org/resources/
publication/transgender-identification-ethics-statement.
L. A. Sharzer et al.
simply renders sexual intercourse infertile. In the
words of Pope Pius XI, writing in 1930, direct
sterilization is not morally permissible because
people “are not free to destroy or mutilate their
members, or in any other way render themselves
unfit for their natural functions.”38
In the United States, the most significant
teaching document of the Conference of Catholic
Bishops on matters of medical ethics is the
Ethical and Religious Directives for Catholic
Health Care Services, now in its sixth edition.
The purpose of this document is “to provide
authoritative guidance on certain moral issues
that face Catholic health care today.”39 Directive
53 expresses the traditional Catholic prohibition
on direct sterilization: Direct sterilization of
either men or women, whether permanent or tem-
porary, is not permitted in a Catholic healthcare
institution. Procedures that induce sterility are
permitted when their direct effect is the cure or
alleviation of a present and serious pathology and
a simpler treatment is not available.40
Official Catholic Teaching
Whereas Evangelical Christians turn first to the
Bible to address moral or theological problems,
and mainline Protestants seek to learn from the
experience of Christians engaging with the pre-
vailing culture, the Catholic Church gives a cen-
tral place to tradition and to the authority of
popes and of bishops in communion with the
pope. It is therefore significant, from a Catholic
perspective, that the topic of GCS has never been
addressed directly by any pope nor by any teach-
ing document authorized by the pope. It has not
been addressed in any public teaching document
from the Congregation of the Doctrine of the
Faith (the doctrinal watchdog of the Catholic
Church), nor is it covered in the extensive ethical
section of the Catechism of the Catholic Church.
This absence of teaching is remarkable given the
Pope Pius XI, Casti Connubii (December 31, 1930), 71.
38 
USCCB (United States Conference of Catholic Bishops)
39 
[37, p. 3].
USCCB, Ethical and Religious Directives, Directive 53.
40 
22  Religious Attitudes Toward Gender-Confirming Surgery
great interest in medical ethics shown by at least
two twentieth-century popes: Pope Pius XII
(1939–1958) and Pope John Paul II (1978–2005).
The United States Catholic Bishops’ Ethical and
Religious Directives makes no explicit mention
of GCS though its prohibition of sterilization
mentioned above has been cited by Catholic hos-
pitals in legal cases to defend the non-provision
of GCS.  The appeal to this directive is doubly
problematic. Even in the case of procedures (such
as genital reconstruction or hysterectomy) which
do cause sterility, it is far from clear that they are
“direct sterilization” in the sense of sterilization
intended as a form of birth control. Furthermore,
the Directive has no application to procedures
(such as mammoplasty or chondrolaryngoplasty)
which may be undertaken as part of surgical tran-
sition but which have no effect on fertility.
Medical and Theological Discussion
In the absence of clear official teaching, Catholic
doctrine on medical ethics is shaped by theolo-
gians and by Catholic clinicians. There has been
discussion of the ethics of GCS by Catholic
moral theologians since the 1950s and increas-
ingly in the last decade or so when the topic has
become more prominent. The predominant view
among theologians has been that GCS involves
mutilation, because it involves destruction of bio-
logical function to address a problem that is psy-
chosocial in origin. On the other hand, a few
theologians have suggested that gender dyspho-
ria might be biological in origin, and in this case
surgery could be understood as legitimate: “if the
biological interpretation of transsexuality is cor-
rect to any considerable degree, then… [in the
case of a FTM transsexual] we could say that
God created a male and that a sex change opera-
tion would be corrective and be similar to other
operations which seek to compensate for, or
overcome, a difficulty that is genetic or
embryological in origin.”41 This interpretation
­ McHugh [41], McHugh [42], Mayer and McHugh [43].
understands gender dysphoria on the analogy of
physiological divergences of sexual development
Moraczewski [38, p. 5].
41 
233
(DSDs also known as “intersex” conditions) and
seeks to justify surgery on that basis. On the other
hand, other Catholic theologians have argued
that, even were the gender incongruence biologi-
cal in origin, surgery would not be permissible.
The aim of surgery in cases of DSD is or ought to
be “to restore as much normal function of one
gender as possible”42 and any destruction of bio-
logical function would still require justification.
Inasmuch as there is an analogy with DSDs, peo-
ple are becoming more aware of the harm that has
been done in the past by drastic and unnecessary
surgery performed on children to conform them
to social expectations of gender.
Since the early 1990s, some Catholic theolo-
gians have argued that GCS could be therapeutic,
in principle, if it were “an effective means of
freeing the patient from an intolerable psycho-
logical conflict and obtaining peace of mind.”43
However, given the immediate functional harm
done by the operation, they have required robust
evidence of long-term benefit and most theolo-
gians remain unconvinced that this has been
demonstrated. In their reading of the evidence,
Catholic theologians have been influenced
strongly by Catholic clinicians, not least by the
work and continued writing of Paul McHugh.44
The predominant attitude of Catholic theolo-
gians, Catholic healthcare professionals, and
Catholic hospitals is thus extreme reluctance to
permit GCS and especially so where the surgery
would compromise sexual or reproductive
function.45
J ewish Teaching Regarding Gender-­
Confirming Surgery
Leonard A. Sharzer
Tonti-Filippini [21, p. 93].
42 
Urbano Navarrete [40, p. 106].
43 
44 
For more details see David Albert Jones “Gender
45 
Reassignment Surgery: A Catholic Bioethical Analysis”
Theological Studies, forthcoming. See also example
Brody et al. [39], Ashley et al. [32, p. 110], Guevin [44],
Eijk et al. [45], Brugger [46], McQueen [47].
234
Introduction
Jewish discourse on bioethical issues draws from
Judaism’s legal tradition (halakhah) as well as its
narrative tradition (aggadah).46 It is a normative
tradition which speaks the language of obligation
rather than the language of rights. Its goal is to
determine whether a particular activity is forbid-
den, permissible, or obligatory. The reasoning is
casuistic and text based relying on precedents
beginning with the Bible, specifically the
Pentateuch, and including rabbinic texts such as
the Talmud,47 medieval codes of Jewish law,48
and responsa literature.49
It is important to understand that Jewish opin-
ion on questions of law is not monolithic. There
is no single authoritative voice analogous to a
pope or church council. Rather, individual rabbis
render opinions/decisions based on textual and
precedential authority. Rabbis, typically relying
on the same texts and precedents, may come to
different conclusions which may be nuanced in
their disagreement or may be diametrically oppo-
site. As might be expected, there are differences
between religious movements within Judaism
(Orthodox, Conservative, Reform, and
Reconstructionist), but even within the various
streams of Jewish thought, there is not necessar-
ily uniformity. I will endeavor in this section to
outline the range of opinions that relate to gender
46 
For a discussion of these traditions see Jakobovits [48,
49]; Leonard Sharzer, Aggadah and Midrash: A New
Direction for Bioethics?, in Jewish Lights, William Cutter,
Ed., Woodstock, VT, 2010 Midrash and Medicine,, Joel
Roth, The Halakhic Process: A Systemic Analysis, JTS
Press, New York, 1986; Dorff [50], Mackler [51], Crane
[52].
The Talmud is comprised of the Mishnah, a code of
47 
Jewish Law compiled by Rabbi Judah the Prince around
the year 200 C.E., and the Gemara, a record of rabbinic
discussion and elaboration of the laws found in the
Mishnah over the next three centuries.
48 
Most notably the Mishneh Torah compiled by Moses
Maimonides, a rabbi and physician, between 1170 and
1180, and the Shulhan Arukh compiled by Rabbi Josef
Karo in 1563.
A genre of literature comprised of the answers to spe-
49 
cific questions of Jewish law by respected rabbinic author-
ities known as poskim, a practice extending from the early
Middle Ages to the present day.
L. A. Sharzer et al.
confirmation surgery (GCS) and the reasoning
underlying them. Before doing so, however, it
will be helpful to look briefly at the Jewish atti-
tude toward gender itself.
Sex and Gender in Jewish Thought
In assigning gender, especially in the case of
transgender and gender-diverse individuals,
Judaism faces several challenges. The first is that
although halakhah is binary in terms of gender,
people are not. The Rabbis50 understood this.
They recognized several types of people who did
not fit the male/female binary. The two most
often mentioned are the tumtum and the androgy-
nos, both persons of unknown or indeterminate
gender. 51 Though none of the people mentioned
by the Rabbis are what we would think of today
as transgender, it is notable that the Rabbis recog-
nized that there were people who did not fit the
halakhic gender binary. Second, Judaism is an
embodied religion. Even for religious streams
within Judaism that tend to be egalitarian with
respect to gender, there are differences in Jewish
law related to anatomic differences between men
and women, such as laws regarding circumcision
and laws of menstrual separation.52
Historically, Judaism like other religions and
cultures assigned gender on the basis of genital
anatomy. With increased knowledge of genetic
and hormonal influences, understanding of gen-
The term Rabbis with an upper case R refers to rabbis of
50 
the Talmudic era.
We can only speculate as to the conditions they were
51 
referring to by these terms. Androgynos, described as a
person whose body neither typically male nor typically
female but had anatomic features of both, was likely what
we would today refer to as an intersex person with ambig-
uous genitalia. Tumtum described a person who is either
male or female but whose gender is unknown because the
organs are hidden by some type of membrane or cover,
which once removed will reveal the true gender.
For a more complete discussion of this subject see
52 
Barmash, P, Women and Mitzvot, Responsa of the
Committee on Jewish Law and Standards of the
Conservative Movement, Y.D. 246:6, 2014 accessed
11/28/2017 at http://www.rabbinicalassembly.org/sites/
default/files/public/halakhah/teshuvot/2011-2020/wome-
nandhiyyuvfinal.pdf.
22  Religious Attitudes Toward Gender-Confirming Surgery
der identity, and greater understanding of DSDs
(disorders/differences of sexual development), it
has become clear that none of these dimensions is
strictly binary, nor is there necessarily any corre-
lation between them. In the more liberal streams
of Jewish thought there has in recent years been a
willingness to assign or accept gender on the
basis of gender identity. Yet there remains a pre-
dilection, particularly in the more traditional
streams even if they accept the notion of gender
identity, to rely on genital anatomy as the pri-
mary determinant of gender. Rabbi Mayer
Rabinowitz in 2003 wrote that a person whose
gender identity differed from that assigned at
birth could be accepted as the other gender, pro-
vided that genital anatomy was surgically altered
to conform to the new gender.53 This is analogous
to a ruling by Rabbi Eliezer Yehudah Waldenberg
in the case of a genetic male infant born with
ambiguous genitalia that his genitalia should be
altered to appear female and he should be reared
as a girl.54 Arguing against Rabbi Waldenberg,
Doctor Fred Rosner and Rabbi Moshe Tendler
wrote that genetic testing was absolutely deter-
minative and “a genetically male infant must not
be surgically modified to permit rearing him as a
female.”55 Despite the differences of opinion
regarding preferences for anatomic or genetic
markers of gender, there has been a reluctance,
particularly in the more traditional streams of
Judaism, to accept gender identity as a valid
marker of gender.
All of the above is a backdrop to Jewish bio-
ethical and legal discourse regarding GCS which
follows two distinct but related lines of inquiry.
The first is whether the surgery is permitted from
the standpoint of Jewish law, and the second
(regardless of whether the surgery is deemed per-
53 
Rabinowitz, ME, Status of Transsexuals, Responsa of
the Committee on Jewish Law and Standards of the
Conservative Movement, EH 5:11.2003 accessed
11/28/2017 at https://www.rabbinicalassembly.org/sites/
default/files/assets/public/halakhah/teshuvot/20012004/
rabinowitz_transsexuals.pdf.
54 
Ziz Eliezer Part 11 Section 78
55 
Rosner, F, and Tendler, M, “Procreation and Sexuality,”
Practical Medical Halacha, Jason Aronson, Northvale,
1997, p. 41.
235
missible) is whether someone who has undergone
GCS is to be considered as having changed gen-
der with respect to religious norms that are differ-
ent for men and women.
In the pre-modern era, rabbis posed the fol-
lowing question: What are the consequences
when a man or a woman becomes the opposite
sex in all ways and in every particular? 56 They do
not say how this change occurs or why, but it
obviously has nothing to do with GCS or what
we would today consider issues of gender iden-
tity. Their main concern appears to relate to the
issue of marriage, specifically whether a mar-
riage entered into prior to the change is still valid
and whether a get (a Jewish writ of divorce) is
necessary to dissolve the marriage. Although
there are a variety of different opinions on that
question which are not particularly relevant to the
current discussion, nevertheless, these discus-
sions are often cited as a precedent by those who
argue that gender is not, in fact, immutable.
In the modern era, most Jewish discourse on
transgender issues addresses the following ques-
tion: “What is the halakhic status of a person who
has undergone GCS?”57 Again the answers vary.
Some poskim (halakhic decisors) say that the sur-
gery does effect a change in gender for halakhic
purposes and is actually required for that indi-
vidual to be accepted as the new gender. Other
authorities say that the surgery has no effect and
that gender is permanent and immutable. Not sur-
prisingly, the majority of those holding the for-
mer view come from the more liberal streams of
Judaism and most of those asserting the latter
view come from the more traditional streams.
See for example Yosef et Ehav 3:5
56 
See for example Sharzer, LA, Transgender Jews and
57 
Halakhah, Responsa of the Committee on Jewish Law and
Standards of the Conservative Movement, EH 5:11.2017b
accessed 11/28/2017 at https://www.rabbinicalassembly.
o rg / s i t e s / d e f a u l t / fi l e s / p u b l i c / h a l a k h a h / t e s h u -
vot/2011-2020/transgender-halakhah.pdf . Rabinowitz op
cit.; CCAR Responsa, Conversion and Marriage after
Transsexual Surgery 5750.8 accessed 6/8/2017at https://
ccarnet.org/responsa/tfn-no-5750-8-191-196/; Ziz Eliezer,
10:25, Chapter 26, Sec. 6. See also Bleich, JD,
Contemporary Halakhic Problems, Volume 1, Ktav
Publishing House, New  York and Hoboken, 1977,
pp. 100–105.
236
Whether or not the rabbis believe that GCS
results in a change of gender, virtually all address
the related question of whether the surgery itself
is permissible in the first place according to
Jewish law. In assessing the permissibility of
GCS, it is important to separate the issues raised
by non-genital GCS, often referred to as top sur-
gery, and genital GCS or bottom surgery.
Non-genital GCS
The questions raised by the many types of sur-
gery transgender people may choose to undergo58
are similar to those raised by cosmetic surgery: Is
the surgery medically necessary? Is it unnatural
and, consequently, prohibited? Does it contradict
the notion that humans are created in the image
of God? Does it violate the general prohibition
against self-wounding? Does it violate the prohi-
bition against intentionally placing oneself in a
risky or dangerous situation?
When these questions have been raised in the
context of cosmetic surgery, most poskim have
been permissive.59 The idea that cosmetic surgery
is somehow unnatural or violates God’s will or
image is an outlier, cited by only one or two rab-
binic authorities, and is not in the mainstream of
Jewish thought for even the more traditional
groups. The two issues that nearly all rabbinic
authorities deal with are the prohibition of self-­
wounding (including permitting others to cause a
wound on one’s body) and placing oneself in an
unnecessarily dangerous situation. One of the
first rabbis to address the question of cosmetic
surgery was Rabbi Mordecai Breisch (cited
above) in 1965. He opined that these prohibitions
were relative and not absolute, and if the surgery
was being done to alleviate pain, and with the
consent of the patient, then those two prohibi-
This would include surgery related to secondary sex
58 
characteristics (e.g. facial feminization surgery, breast
augmentation, mastectomy and male chest reconstruction,
etc. The issues raised by these operations are relevant to
genital reconstructive surgery (GRS) as well, but GRS
raises other issues that are unique to it.
59 
See for example Breisch, Helkat Yaakov 3:11, Feinstein,
Iggerot Moshe HM 2:66, Yosef, Yabi’a Omer v.8:12.
L. A. Sharzer et al.
tions would not apply. Rabbi Breisch went fur-
ther to assert that relief of psychological pain or
distress was as valid a justification for surgery as
relief of physical pain. Extrapolating from the
reasoning regarding cosmetic surgery to gender
dysphoria, a condition which can cause distress,
sometimes severe enough to lead to suicide, some
rabbis have argued that GCS should be permit-
ted.60 It is axiomatic in Jewish thought that saving
a life overrides nearly all halakhic objections, but
even absent threat to life, symptoms of pain and
distress, to the extent they can be relieved by sur-
gery, are certainly enough to overcome objec-
tions based on the prohibitions of self-wounding
and endangerment.
Genital GCS
In addition to the questions raised by non-genital
GCS, genital GCS raises specific questions
unique to it. The Bible, in the Book of Leviticus,
specifically prohibits castration (And that which
is mauled or crushed or torn or cut you shall not
offer unto the Lord; nor should you do this in
your land.61). The specific biblical prohibition
applies only to males and only to animals.
However, rabbinic exegesis over the centuries has
extended the prohibition to humans, both male
and female. This prohibition is, however, regu-
larly abrogated in cases of medical necessity, for
example, cancer of the ovary or testicle when
they are thought best treated by surgery. Even in
cases where surgical castration is recommended
for the treatment of conditions not affecting the
gonad itself, such as prostatic cancer or prophy-
lactic oophorectomy for carriers of the BRCA
mutation, the procedures tend to be accepted.
This is the reasoning applied by those rabbis,
such as Rabbi Rabinowitz, who find GCS
permissible:
See Rabinowitz, op cit, and Sharzer, op cit.
60 
Leviticus 22:24. While this prohibition refers specifi-
61 
cally to animals, the Rabbis extended the prohibition to
humans as well. See B Shabbat 110b, Mishneh Torah Hil’
Issurei Biyah 16:10, Shulhan Arukh EH 5:11.
22  Religious Attitudes Toward Gender-Confirming Surgery
It would seem that the people undergoing the long
process of SRS as stated in the Standards of Care,
are doing so because they are suffering from gen-
der dysphoria, and SRS is treating the patient with
gender dysphoria. Their pain and anguish is great
and there is no doubt that they are suffering. This
has led them to undergo the long and difficult pro-
cedures outlined in the standards of care. For them
SRS is being done letovat ha-holeh, for the benefit
of the patient, and therefore would be permissible,
just as it would be permissible to help treat a physi-
cal ailment. We have permitted other procedures
for mental ailments and have said that the mental
illness is to be treated in the same way as a physical
one. Therefore SRS may be permissible and the
prohibition against castration can be overridden in
this case.62
For others, such as Rabbi J.  David Bleich,63
“Sex-change operations involving the removal of
sexual organs are clearly forbidden on the basis
of the explicit Levitical prohibition ‘And that
which is mauled or crushed or torn or cut you
shall not offer unto the Lord; nor should you do
this in your land.’ (Lev 22:24).”64 He also cites, as
support for this view, the opinion of Rabbi Meir
Amsel (Ha-Ma’or, kislev-tevet 5733) that the
surgery involves a violation of the biblical prohi-
bition: “A woman shall not wear that which per-
tains to a man, nor shall a man put on a woman’s
garment.” (Deut 22:5)65 Rabbis who follow this
line of reasoning generally accept the validity of
a diagnosis of gender dysphoria and recognize
the need for compassion for afflicted individuals
but maintain that it should be treated psychologi-
cally, not surgically.
Conclusion
There is a wide range of Jewish thought as it
relates to gender identity and its validity as a
determinant of gender for purposes of halakhah
(Jewish law). In the same way, there are diverse
views as to whether GCS (specifically genito-
plasty) affects a change in gender and whether
62 
Rabinowitz op. cit.
63 
See citation Fn 12.
64 
Bleich op cit, p. 100.
65 
Ibid.
237
such surgery is permissible in the first place.
These views range from the position that the
surgery is absolutely forbidden in all circum-
stances, to the position that surgery is permis-
sible but not mandatory, to the view that surgery
is not only permissible but required in order for
the person to be considered the new gender. Non-
genital GCS (top surgery) is generally viewed
more permissively, although many/most who
hold that removal of non-diseased sex organs
is strictly forbidden tend to believe that gender
dysphoria is a condition which should be treated
non-operatively.
Islamic Theology and Gender-­
Confirming Surgery
Mehrdad Alipour
Introduction
Thanks to modern medical technologies, gender-­
confirming surgery (GCS) has been performed
since the middle of the twentieth century.
Although GCS is considered as a great achieve-
ment which has a positive effect on individuals
who wish to undergo this transition, it has
resulted in challenges for religions, including
Islam. Muslim theologians and jurists have
encountered many questions as the demand for
GCS has grown among Muslim transgender,
transsexual, and intersex people. The first ques-
tion is whether GCS is permissible in Islām in
the first place. And if so, to what extent it can be
performed. Moreover, if it is permissible for all
or some of the people mentioned above to
undergo GCS, we need to examine whether it is
a mandatory duty for them under Islamic Sharīʿa
law to undergo GCS or whether they can choose
to undergo surgery or not. In order to deal with
these questions, Muslim scholars initiated a
debate on the issue of GCS more than five
decades ago. However, the attitude of Islamic
scholarship with regard to GCS is still a chal-
lenging subject for Muslim scholars. On the one
hand, GCS is mostly regarded as sinful, thus pro-
238
hibited (ḥarām) in Islam by both Sunnī and Shiʿa
traditional scholars [67, 77, 84]. On the other
hand, in the late 1980s, GCS was legalized
(made ḥalāl) in shariʿa and/or in state law by the
fatwās (Islamic legal opinions) of Āyatullāh
Khomeini (a grand Shīʿī Āyatullāh and the leader
of the 1979 Iranian Revolution) in Iran and
Shaykh al-Ṭanṭāwī (Mufti of the Arab Republic
of Egypt and Shaykh of al-Aẓhar in 1996–2010)
in Egypt. It seems that these fatwās should ini-
tially be considered as being evidence of a toler-
ant attitude of Islam toward Muslim individuals
who wish to undergo this transition. In order to
understand the issue from an Islamic perspec-
tive, I shall briefly review the concepts of inter-
sex, transsexual, and transgender individuals,
and then I discuss the different attitudes of
Islamic scholarship toward GCS.
Intersex, Transsexual,
and Transgender Individuals
The term “transgender,” according to Muslim
scholars, describes both women and men who
feel that they are trapped in the wrong bodies
and may decide to change their bodies through
gender-­confirming surgery [74]. However,
some gender experts, transgender activists and
transgender people [66] do not fully agree with
this description. They tend to categorize the
group mentioned above as transsexual people.
In this more recent perspective, the term trans-
gender defines people whose gender identities
do not correspond with the sex identified at
birth (see the entry of this word at the Oxford
Dictionary Online and Merriam Webster
Online).66
Muslim scholars identify the concept of
“intersex” as khunthā. In traditional Islamic
scholarship, a khunthā is a person who pos-
sesses both or ambiguous male and female sex
Beemyn and Rankin (2011, p. 6) describe the term trans-
66 
gender as “all individuals whose gender histories cannot
be described as simply male or female, even if they now
identify and express themselves as strictly female or
male.”
L. A. Sharzer et al.
organs or genitals. Muslim jurists have distin-
guished between two types of khunthā [73, 80].
The first group of khunthā includes individuals
identified as al-khunthā ġair mushkil (determi-
nate/unambiguous intersex). According to the
Muslim jurists, this first group has a “true gen-
der or sex” as male or female, which can be
determined through physical signs,67 before or
after puberty. The second group of khunthā
includes people who have physical features
which, according to these jurists, cannot be dis-
tinguished within the gender binary as male or
female, before or after puberty. This second
group is called al-khunthā mushkil (indetermi-
nate/ambiguous intersex).
GCS and Islamic Theology
of Opponents and Defenders
Muslim jurists who oppose gender-confirming
surgery simply forbid the GCS procedure. They
believe that Muslims must be identified as female
or male based on their sex organs, and conse-
quently have to perform the Islāmic mandatory
practices as a male or female based on their sex
organs. These theologians have tried to enlist a
variety of arguments to support the prohibition of
GCS [68, 69], but their most important argument,
as the Islāmic Fiqh Council of the Muslim World
League in 1989 (session 11, resolution 6) stated,
is that of “wrongly interfering in God’s creation.”
Briefly explained, this means God has created
everything as it is, including human beings, and
God does not make mistakes. Therefore, what a
person is, in fact, is her or his God-given nature.
If GCS is performed then God’s Own creation is
Although, as we will see later, some Muslim scholars
67 
currently try to apply more modern medical terms to
determine the gender or sex of khunthā, traditional schol-
ars mostly identify khunthā’s gender or sex through bio-
logical signs, such as by looking at which genitalia the
khunthā urinates from or the one the urine initiates from
or ends from (during childhood and before puberty) or by
observing the facial hair and semen for males and the
growth of breasts and menstruation for females (after
puberty). For a comprehensive discussion on this issue,
see: Sanders [53].
22  Religious Attitudes Toward Gender-Confirming Surgery
interfered with, a creation no one in existence has
any right to alter. There is a verse in the Qur’ān
(4: 119) that says:
And I will mislead them, and I will arouse in them
[sinful] desires, and I will command them so they
will slit the ears of cattle, and I will command them
so they will change the creation of Allah and who-
ever takes Satan as an ally instead of Allāh has cer-
tainly sustained a clear loss.68
Some Muslim scholars use this verse to argue
that God commands us not to change the creation
of Allāh. Otherwise, Satan will take shape instead
of Allāh and we will be acting against God’s
intrinsic nature.
However, unlike the group above, other schol-
ars, such as Khomeini and al-Tantāwī, seem to
believe that the argument presented against
GCS cannot justifiably forbid it in Islam. In
their opinion, this argument of “wrongly inter-
fering in God’s creation,” which is based on
the Qur’ānic verse, does not apply to GCS. This
is because, according to some exegetists of the
Qur’ān and Sunna (sayings, deeds, and
endorsements of Muḥammad) [69], in this
verse changing the creation of Allāh does not
refer to body change or to GCS but refers to
changing sharīʿa law and God’s commands.
Therefore, the forbidding of change mentioned
in the Qur’ān does not apply to gender-con-
firming surgery.
Khomeini and Shiʿa Theology of GCS
It seems that the first response to the issue of
GCS among Muslim scholars was by Āyatullāh
Khomeini, in his book Taḥrīr al-Wasīla, in 1964.
Khomeini addressed this issue in a section
devoted to “The Changing of Gender/Sex.” This
section includes ten problems. Problem 1 is a
fatwā which explicitly discusses the permissibil-
ity of GCS for every individual, including trans-
sexual, transgender and khunthā people.
Subsequent problems deal with the specific
The translation of the verse is by the Sahih International
68 
translation of the Qur’ān.
239
results of a sex change, such as the status of a
person’s marriage and kinship following surgery.
Let’s take a look at the fatwā:
It seems that gender confirming surgery from
male-­to-­female is not forbidden (harām) [in Islām]
and vice versa, and it is also not forbidden for a
khunthā undergoing it to be attached to one of the
genders [female or male]; and does gender con-
firming surgery become obligatory if a woman
finds in herself [sensual] desires similar to man’s
desires or some evidence of masculinity in herself–
or a man finds in himself [sensual] desires similar
to the opposite gender or some evidence of femi-
ninity in himself? It seems that [in such a case] if a
person really belongs to a [determined] gender,
gender confirming surgery is not obligatory
(wājib), but the person is still eligible to change
her/his gender into the opposite gender.69
(Khomeini [72], Vol. 2, p. 626)
Regarding the fatwā, Khomeini explicitly
discusses the permissibility of GCS in Islām
and, unlike Najmabadi’s understanding [76], it
should be considered as a definite fatwā. In fact,
in his first sentence Khomeini issues the fatwā
of the permissibility of GCS generally for every
individual who wishes to change his/her body.
In the second and third statements, he specifi-
cally distinguishes intersex (Khunthā) and
transgender/transsexual persons both transmen
and transwomen, as people who are definitely
allowed to undergo GCS.  Finally, he mentions
that this surgery is not mandatory for these
groups which means they can choose to live as
they are without undergoing gender-confirming
surgery.
This fatwā seems to be forgotten by the
authorities of post-revolutionary Iran. Thanks to
the struggles of Maryam Khatoon Mulkara (a
transwoman who convinced Khomeini to issue a
specific fatwā70 on her case in 1987 [71]), this
earlier fatwā received the attention of the Islamic
government of Iran and made them follow the
fatwā and change the state law, thrusting Iran into
the role of a global leader on GCS.
Translation of the fatwā is by the author.
69 
An image of this newer fatwā in Farsi can be seen here:
70 
h t t p : / / w w w. f o r u m . m a h t a a . c o m / T h r e a d
‫سنت‬-‫اهل‬-‫و‬-‫اسلام‬-،‫جنسیت‬-‫تغییر‬.
240
Following this fatwā, some of Khomeini’s
students tried to justify it [70, 75]. But they
were then faced with another problem: the pro-
cedure of GCS itself. As part of the procedure,
the surgeons and their assistants must see or
touch the genitalia of the patient, which is for-
bidden in Islam. They, therefore, returned to
the original dictate, that GCS which is not
urgent must be prohibited. This means the
fatwā should be limited to the most essential
cases. Khomeini’s fatwā, however, did not
have such a limitation. Elsewhere [65] I have
explained that, based on Khomeini’s theologi-
cal approach, it seems that he did not believe in
such traditional limitations for surgery, because
of the new cultural situation regarding human
life.
 l-Τ̣ anṭāwī and His Cautionary
A Muslim World League’s Fatwa
Position Toward GCS
In 1988, responding to a query on a transwoman
named Sally Abd Allah, al-Τ̣anṭāwī issued a
fatwā allowing some cases of GCS.71 Since the
fatwā is long and there is no need to consider all
of it, a summary of the fatwā made by the man
himself will be quoted here.
To sum up: It is permissible to perform the [GCS]
operation in order to reveal what was hidden of
male or female organs. Indeed, it is obligatory to
do so on the grounds that it must be considered a
treatment, when a trustworthy doctor advises it. It
is, however, not permissible to do it at the mere
wish to change sex from woman to man, or vice
versa.72
Based on al-Ṭanṭāwī’s fatwā, it is permis-
sible for individuals to undergo GCS “in order
to reveal what was hidden of male or female
organs.” Although he does not explicitly
71 
Skovgaard-Petersen ([82], p. 3 & 1995, http://quod.lib.
umich.edu/j/jii/4750978.0002.302?view=text;rgn=main)
explains that al-Ṭanṭāwī copied his fatwā “word-for-
word” from a fatwā issued by his predecessor Shaykh
Jādd al-Haqq Ali Jādd al-Haq a decade earlier on the
response to a question from the Malaysian Center for
Islamic Research in l981.
Translation of the fatwa is by Skovgaard-Peterson [83].
72 
L. A. Sharzer et al.
address transsexual, transgender and intersex
people in his fatwā, it seems that al-Ṭanṭāwī
accepts GCS as treatment for those individu-
als who feel that they are trapped in the wrong
body and want to discover their real gender.
In his mind, through GCS, what may be dis-
covered is one’s real gender/inward essence
(batin), which is covered by an outward
appearance (zahir). The important point is
that the whole process, including the opera-
tion, must be regarded as treatment. Given that
an operation is the best treatment, or the only
way to be cured, s/he must undergo surgery.
Conversely, al-Tantawi emphasizes it is not
permissible to carry out the operation at the
mere wish or whim of the patient, that is, to
change sex from one gender to another.
The Islamic Fiqh Council in its 11th session
(held in Saudi Arabia between 19 and 26
February 1989) discussed this subject and issued
a fatwā on GCS (The Sixth Fatwa Resolution on
Change of Sex from Male to Female and Vice
Versa.
Based on this fatwā, if a person is a khunthā
ġair mushkil, i.e., an individual who possesses
signs of both female and male sexes, medical
treatment (through GCS or hormone therapy)
would be permissible for them. However, every
single case must be examined to explore whether
the male or female sex is dominant in order to
medically treat the patient accordingly. In fact,
this fatwā considers people who are al-khunthā
ġair mushkil as sick individuals who require
treatment.
The fatwā, however, does not permit trans-
sexual and transgender people who enjoy having
“the complete sex organs” to undergo treatment
or surgery. Therefore, regarding this fatwā, any
attempt from these individuals to perform GCS
is a crime and deserve punishment. Moreover,
this fatwā does not mention the situation of
al-khunthā mushkil and whether they are permit-
ted to undergo hormone therapy or perform
surgery.
22  Religious Attitudes Toward Gender-Confirming Surgery
 he Approach of Malaysia’s Council
T  uddhist Attitudes Toward Gender-­
of Islamic Religious Affairs to GCS
In Malaysia, the National Council of Islamic
Religious Affairs (NCIRA) is in charge of
Sharīʿa law in the country. Regarding trans-
sexual and transgender individuals, NCIRA
considers this operation prohibited as of the
1983 fatwā (Shogo [81], http://www.newman-
dala.org/tackling-sex-re-assignment-surgery-
malaysia/). The council, however, issued
another fatwā in relation to khunthā people in
2006 [85] in which NCIRA tries to use more
modern terms to distinguish different types of
intersex people. According to this fatwā, GCS
and hormone therapy for intersex individuals
with 46 XX CAH brought up as male are per-
missible to bring them back to their original
gender which is female. Moreover, people with
46, XY AIS raised as female also are permitted
to undergo GCS or hormone treatment with the
consideration that the surgery “psychologi-
cally” or “biologically” does not make trouble
for the patient. But for persons with 46, XY
AIS raised as “female, but diagnosed only after
the person has already grown up, the person
can continue a normal life and the gender is
recognized from his/her [body build] and the
[appearance] of the genitalia. Surgery to
remove the testes (if any) is permissible to pre-
vent the risk of cancer.”
Conclusion
As this brief review of Muslim scholars’
approaches to GCS shows, although many still
believe that GCS is generally prohibited in Islam,
some scholars issued fatwās in favor of
GCS.  Regarding such fatwās, Khomeni’s fatwā
on GCS guarantees a more tolerant approach
toward this operation as it permits this transition
for every individual who wishes to change his/her
body. Moreover, his fatwā does not seem to link
GCS with illness. In contrast, other fatwās dis-
cussed here consider the whole procedure as
treatment and see people who wish to undergo
this surgery as sick and in need of treatment.
241
B
Confirming Surgery
Kelsey Jacob Pacha
To speak about Buddhism as one discreet spiri-
tual entity is not possible, as Buddhism can be
understood as a religion, a philosophy, and a
practice. There are three major Buddhist tradi-
tions: Theravada, Mahayana, and Vajrayana (or
Tibetan), which are variously practiced in differ-
ent parts of the world and deeply influenced by
culture, geography, and history. This section will
focus on Buddhism as it is interpreted in the West
(particularly in America), with brief mentions of
its engagement with gender in other cultural con-
texts. Buddhist philosophy, text, and tradition’s
resources for gender transgression will be dis-
cussed and brief recommendations for surgeons
working with Buddhist patients offered.
Some scholars believe Buddhism is essen-
tially neutral on issues of transgender identity
and gender non-conformity.73 Buddhism tends
not to operate out of hierarchical institutions that
issue authoritative statements on issues like gen-
der confirmation surgery but rather provides
spaces for people to learn and practice. This
enables the tradition to operate within a broad
spectrum of cultural contexts. American Buddhist
communities, on the whole, tend to support trans-
gender and gender non-conforming people who
receive gender confirmation surgery, although
there is no unified formal agreement on the issue.
The American iteration of Soka Gakkai
International (SGI), a Mahayana tradition, has an
active LGBTQ network, Courageous Freedom,
which develops resources for LGBT Buddhists
and participates in activism.74 Sources indicate
that most American Buddhist groups accept
transgender and gender-diverse people into their
monasteries and schools, allowing them to be
ordained, to teach, and to participate in commu-
nity. 75 In America, it is likely that TGNC people
who receive gender confirmation surgery will be
Cabezon [54, p. 94].
73 
Soka Gakkai International- USA [55].
74 
Human Rights Campaign [56].
75 
242 L. A. Sharzer et al.

able to find an accepting white American Many Buddhist communities throughout the
Buddhist community, though these communities world have interacted with and upheld the gifts of
may not reflect the individual’s cultural or ethnic people who identify differently than their sex
identity. assigned at birth. Several countries heavily influ-
A foundational teaching of Theravada enced by Buddhism, like Thailand and India,
Buddhism, called the Three Marks of Existence, have acknowledged the presence of transgender
states that experience is marked by imperma- and gender non-conforming people for thousands
nence, suffering, and the absence of the self. of years through the existence of a third sex in
Impermanence refers to the notion that every- their culture. Often, these individuals become
thing in the world, tangible and intangible, is castrated and honored as wise, spiritually gifted
fleeting. Suffering arises from attempting to hold leaders, such as the acault of Myanmar or the
onto that which is impermanent. The absence of hijras of India.78 The first transgender man known
self contends that there is no eternal soul, perma- to have undergone sex reassignment surgery in
nent essence, or consistent identity that exists the 1940s, Michael Dillon, later became a
beyond human creation and maintenance. The Buddhist monk and was largely accepted as a
ego-self, including our personality traits, our male Buddhist, although one of his teachers
social location, and our history, is a false self. 76 threatened to out him in a prominent Buddhist
Thus, the notion of an internal gender identity—a journal.79
stable essence constituting a sense of self—can Some Buddhist texts acknowledge the histori-
be problematic in Buddhism. Living the teach- cal existence of gender transgressors in society.
ings of the Buddha entails a path in which indi- The Vinaya, a set of rules for monks, acknowl-
viduals slowly release the illusion of selfhood. edges the existence of pandakas, people who did
All desires—including the desire to transition— not fit into normative gender and sexual catego-
can be seen as transient, not offering lasting hap- ries in modern-day India. These include people
piness. Teachers and practitioners may differ on born with ambiguous genitalia, people seemingly
how they perceive the authenticity of one’s gen- born without obvious sex organs, and people
der identity and whether they believe altering the whose sexual and gendered characteristics
body, rather than the mind, is advisable on the seemed to change in accordance with the moon
path to enlightenment. However, others argue cycle.80 The Pali Canon, the words of the Buddha,
that in order for an individual to truly accept the contains a story about a male adherent named
teachings of the Buddha and to be present to Soreyya, whose infatuation with a Buddhist elder
practice, they must be fully comfortable and changed him into a woman. He got married to a
present in their bodies.77 man and bore two children before changing back
Another principle invoked when discussing to a man and asking forgiveness for what he had
LGBT issues in Buddhism comes from the Five done. 81 In Mahayana Buddhism, there are bod-
Precepts, ethical guidelines supporting the path hisattvas (enlightened humans who refuse nir-
to enlightenment. It states, “I am aware of the vana in order to elevate humanity’s consciousness)
suffering caused by sexual misconduct.” Some whose gender is fluid—Avalokiteshvara, a male
Buddhist traditions understand any non-­bodhisattva, is said to transform into female
heteronormative expression of sexuality and gen- Kuan Yin when overcome with compassion for
der as violating this precept, while others interpret women and children.82
it as an ethical imperative to be authentic to one’s
gender and sexual identities. Differences are
often due to the culture Buddhism is operating 78 Mollenkott [7, pp. 159–60].
within. Jivaka and Stryker [59, pp. 230–31].
79 

Likhitpreechakul [60].
80 

76 
Post [57, p. 335]. Bodhi [3, DhA.i.324ff].
81 

Tisdale et al. [58].

77 
Conner et al. [61, pp. 78, 208].
82 
22  Religious Attitudes Toward Gender-Confirming Surgery
However, Buddhist-based rejection of trans-
gender people does exist.83 Some trans people
have experienced condemnation by self-­identified
Buddhist communities. Cultural beliefs about
gender roles, the spiritual goals of sexuality, and
the spiritual purpose of the body may influence
the application of Buddhist precepts to a person’s
gender journey. For example, some Japanese peo-
ple believe a person’s body should be preserved
completely after death so they can maintain their
spiritual integrity as an ancestor. Any alteration of
one’s body parts during their lifetime could
threaten their spiritual destiny and presence after
death, not to mention the gender-­related responsi-
bilities they have within their families.84
For surgeons, the most important aspect of a
patient’s Buddhist identity is attending to the
level of conflict they experience with their desire
to receive gender confirmation surgery, whether
this is due to ethical or cultural misgivings of
their Buddhist community. It is important to
remind them that supportive sanghas, meditation
groups, and other Buddhist resources exist, even
if not in their area. Online support groups, dharma
talks, and remote meditation groups are available
to support their gender and spiritual journeys and
help connect them with other TGNC Buddhists.85
References
1. Jones RP, Cox D.  America’s changing religious
identity: findings from the American values Atlas.
Washington, DC: Public Religion Research Institute.
September 6, 2017. https://www.prri.org/research/
american-religious-landscape-christian-religiously-
unaffiliated/
2. Pew Research Center. A survey of LGBT Americans:
attitudes. “America’s changing religious land-
scape.” Washington, DC: Pew Research Center, May
12, 2015. http://www.pewforum.org/2015/05/12/
americas-changing-religious-landscape/
3. Bodhi. In the Buddha’s words: an anthology of
discourses from the Pāli Canon. Boston: WIsdom
Publications; 2005.
83 
Mosbergen [62].
84 
Post [63, p. 328].
85 
One such resource can be found: San Francisco LGBT
Sangha [64].
243
4. Markham C, Wolf T.  People of faith support trans-
gender rights. Center for American Progress (blog),
March 29, 2017. https://www.americanprogress.
org/issues/religion/news/2017/03/29/429291/
people-faith-support-transgender-rights/
5. Payne LC. The body. In: Tigert LMC, Tirabassi MC,
editors. Transgendering faith: identity, sexuality, and
spirituality. Cleveland: Pilgrim Press; 2004.
6. Mollenkott VR, Sheridan V.  Transgender journeys.
Eugene: Wipf & Stock Pub; 2010.
7. Mollenkott VR.  Omnigender: a trans-religious
approach. Cleveland: Pilgrim Press; 2001.
8. Tanis JE.  Trans-gendered: theology, ministry, and
communities of faith. Cleveland: Pilgrim Press; 2003.
9. Stewart S. My story. In: Tigert LMC, Tirabassi MC,
editors. Transgendering faith: identity, sexuality,
and spirituality. Cleveland: Pilgrim Press; 2004.
p. 82–6.
10. Moore A. Transcending physical boundaries and sick
religion: the story of a transsexual mystic. In: Tigert
LMC, Tirabassi MC, editors. Transgendering faith:
identity, sexuality, and spirituality. Cleveland: Pilgrim
Press; 2004. p. 102–10.
11. Kline C, Schrock D. What is gender reassignment sur-
gery? A medical assessment. The Council for Biblical
Manhood and Womanhood: a coalition for biblical
sexuality, May 7, 2015. https://cbmw.org/topics/cul-
ture/studies-what-is-gender-reassignment-surgery-a-
medical-assessment-with-a-biblical-appraisal/
12. The Council on Biblical Manhood and Womanhood.
Nashville statement: a coalition for biblical sexu-
ality. The Council on Biblical Manhood and
Womanhood, August 29, 2017. https://cbmw.org/
nashville-statement/
13. Christian Medical and Dental Associations House
of Representatives. Transgender identification ethics
statement. Christian Medical and Dental Associations,
April 2016. http://cmda.org/resources/publication/
transgender-identification-ethics-statement
14. Council on Biblical Manhood and Womanhood.
Danvers statement. Council on Biblical Manhood
and Womanhood, November 1988. https://cbmw.org/
about/danvers-statement/
15. “Correspondence Guidelines.” Watch tower Bible and
tract society of Pennsylvania, 2007.
16. Presidency, The First, and Council of the Twelve
Apostles of the Church of Jesus Christ of Latter-
Day Saints of The Church of Jesus Christ of Latter-
day Saints. The family: a proclamation to the world.
September 23, 1995. https://www.lds.org/topics/
family-proclamation?lang=eng
17. The Church of Jesus Christ of Latter-Day Saints.
Handbook 1: Stake Presidents and Bishops. The
Church of Jesus Christ of Latter-Day Saints, Salt Lake
City, 2010.
18. Allen S. Mormon man risks excommunication by shar-
ing his transition. The Daily Beast, March 16, 2016.
https://www.thedailybeast.com/articles/2016/03/16/
mormon-man-risks-excommunication-by-sharing-
his-transition
244
19. Seventh-Day Adventist World Church. Statement
on Transgenderism. Seventh-Day Adventist Church,
April 12, 2017. https://www.adventist.org/en/infor-
mation/official-statements/statements/article/go/-/
statement-on-transgenderism/
20. McDaniel NJ. The Phoenix will fly. In: Tigert LMC,
Tirabassi MC, editors. Transgendering faith: identity,
sexuality, and spirituality. Cleveland: Pilgrim Press;
2004. p. 62–6.
21. Tonti-Filippini N.  Sex reassignment and catholic
schools. Nat Cathol Bioethics Q. 2012;12:85–97.
22. Bauchman CJBH.  The relationship between spiri-
tual beliefs and practices to psychological well-being
among Latino gay, lesbian, bisexual, transgender,
and questioning individuals. Dissertation. Pacific
University; 2012. http://commons.pacificu.edu/
spp/384/
23. McQueeney K. ‘We are God’s Children, Y’All:’ race,
gender, and sexuality in lesbian- and gay-affirming
congregations. Social Problems. 2009;56(1):151–73.
24. Pitt RN.  Still looking for my Jonathan’: gay
black Men’s management of religious and sex-
ual identity conflicts. Journal of Homosexuality.
2010;57(1):39–53.
25. Tirabassi MC.  Prayers for congregational use. In:
Tigert LMC, Tirabassi MC, editors. Transgendering
faith: identity, sexuality, and spirituality. Cleveland:
Pilgrim Press; 2004. p. 115–23.
26.
Herek GM, Norton AT, Allen TJ, Sims
CL. Demographic, psychological, and social charac-
teristics of self-identified lesbian, gay, and bisexual
adults in a US probability sample. Sexuality Research
& Social Policy. 2010;7(3):176–200.
27. Pew Research Center. A survey of LGBT Americans:
attitudes, experiences, and values in changing times.
Washington, DC: Pew Research Center, June 2013.
http://www.pewsocialtrends.org/files/2013/06/SDT_
LGBT-Americans_06-2013.pdf
28. James SE, Herman JL, Rankin S, Keisling M,
Mottet L, Ma’ayan A.  The report of the 2015
U.S.  Transgender survey. Washington, DC: The
National Center for Transgender Equality, December
2016. http://www.transequality.org/sites/default/
files/docs/usts/USTS%20Full%20Report%20-%20
FINAL%201.6.17.pdf
29. Midnight D.  Holistic health for transgender folks.
Ohlone Herbal Center, December 2009. http://www.
ohlonecenter.org/wp-content/uploads/2017/06/
Midnight_D_Transgender_Care.pdf
30. Sigler K. TransNatural for professionals short hand-
out. San Francisco Herbalist; 2016. http://www.
sfherbalist.com/herbs-for-transgender-folx/
31. Stephens T.  The principle of totality does not jus-
tify sex reassignment surgery. Ethics Medics.
2016;41(11):1–2.
32. Ashley B, Deblois J, O’Rourke K. Health care ethics:
a Catholic theological analysis. 5th ed. Washington,
DC: Georgetown University; 2006.
L. A. Sharzer et al.
33. Daly TTW. Gender dysphoria and the ethics of trans-
sexual (i.e. gender reassignment) surgery. Ethics
Medicine. 2016;32:39–53.
34. O’Donovan O.  Transsexualism and Christian mar-
riage. J Relig Ethics. 1983;11:135–62.
35. Eijk WJ.  Is medicine losing its way? A firm foun-
dation for medicine as a real therapeia. Linacre Q.
2017;84(3):208–19.
36. Kelly GA. Pope Pius XII and the principle of totality.
Theol Stud. 1955;16:373–96.
37. USCCB (United States Conference of Catholic
Bishops). Ethical and religious directives for catholic
health care services. 5th ed. Washington, D.C: United
States Conference of Catholic Bishops; 2009.
38. Moraczewski AS.  Sex change’ operations. Ethics
Medics. 1977;2:4–5.
39. Brody BA, et al. Marriage, morality, and sex-change
surgery: four traditions in case ethics. Hast Cent Rep.
1981;11(4):8–13.
40. Navarrete U. Transsexualism and the canonical order.
Nat Cathol Bioethics Q. 2014;14:105–18.
41. McHugh P. Surgical sex. First Things. 2004;147:34–8.
42. McHugh P. Transgender surgery Isn’t the solution: a
drastic physical change doesn’t address underlying
psychosocial troubles. Wall Street Journal, 12 June
2014.
43. Mayer LS, McHugh P. Sexuality and gender: findings
from the biological, psychological, and social sci-
ences. New Atlantis. 2016;50(3):86–116.
44. Guevin MB.  Augmentation mammoplasty for male-
to-female transsexuals. Nat Cathol Bioethics Q.
2009;9:453–8.
45. Eijk W, Hendriks LJM, Raymakers JA.  Manual of
Catholic medical ethics. Ballarat: Connor Court;
2014. p. 460–6.
46. Brugger EC. Catholic hospitals and sex reassignment
surgery: a reply to Bayley and Gremmels. Nat Cathol
Bioethics Q. 2016;16:587–97.
47. McQueen M. Catholic teaching on transgender (gen-
der dysphoria). Bioethics Matter. 2016;14(1):1–4.
48. Jakobovits I.  Jewish medical ethics: a compara-
tive and historical study of the Jewish religious atti-
tude to medicine and its practice. New  York: Bloch
Publishing Company; 1959.
49. Jakobovits I.  Methodologic problems: the case of
Jewish medical ethics. In: Dorff E, Newman L, edi-
tors. Contemporary Jewish ethics and morality.
New York: Oxford University Press; 1995. p. 129–93.
50. Dorff E. Matters of life and death: a Jewish approach
to modern medical ethics. Philadelphia: Jewish
Publication Society; 1998.
51. Mackler A, editor. Life and death responsibilities
in Jewish biomedical ethics. New  York: The Jewish
Theological Seminary; 2000.
52. Crane J. Narratives and Jewish bioethics. New York:
Palgrave Macmillan; 2013.
53. Sanders P. Gendering the ungendered body: hermaph-
rodites in medieval Islamic law. In: Baron B, Keddie
22  Religious Attitudes Toward Gender-Confirming Surgery
N, editors. Women in middle eastern history: shift-
ing boundaries in sex and gender. New Haven: Yale
University Press; 1991. p. 74–95.
54. Cabezon JI.  Homosexuality and buddhism. In:
Swidler A, editor. Homosexuality and world religions.
1st ed. Valley Forge: Trinity Press International; 1993.
p. 81–101.
55. USA, Soka Gakkai International-. Courageous free-
dom: SGI-USA’s LGBTQ community –. Soka Gakkai
International  - USA. www.sgi-usa.org/2016/05/19/
courageous-freedom-sgi-usas-lgbtq-community/.
Accessed 8 Dec 2017
56. Human Rights Campaign. Stances of Faiths on
LGBTQ Issues: Buddhism. Human Rights Campaign.
http://www.hrc.org/resources/stances-of-faiths-
on-lgbt-issues-buddhism/. Accessed 8 Dec 2017.
57. Post SG.  Buddhism, bioethics in. In: Encyclopedia
of bioethics. New York: MacMillan Reference USA;
2004b.
58. Tisdale SJ, Libenson NH, Holocek A. Does my trans-
gender identity conflict with Buddhist teachings on
no-self? Lion’s Roar: Buddhist Wisdom of Our Time,
July 31, 2017. https://www.lionsroar.com/does-my-
transgender-identity-conflict-with-the-teachings-on-
no-self/
59. Jivaka MD-L, Stryker S. Out of the ordinary: a life of
gender and spiritual transitions. Edited by Jacob Lau
and Cameron Partridge. 1st ed. New York: Fordham
University Press; 2016.
60. Likhitpreechakul P.  Homophobic Law Has NO
BASIS in Buddhism. The Nation. April 3, 2015, sec.
Opinion. http://www.nationmultimedia.com/detail/
opinion/30257329
61.
Conner RP, Sparks D, Sparks M, Anzaldua
G. Cassell’s encyclopedia of queer myth, symbol, and
spirit: gay, lesbian, bisexual, and transgender lore.
London/Herndon: Cassell; 1997.
62. Mosbergen D.  Two-faced Thailand: the ugly side of
‘Asia’s Gay Capital’. Huffington Post, October 20,
2015, sec. The WorldPost. https://www.huffington-
post.com/entry/lgbt-thailand_us_5616472ee4b0dbb8
000d30a6
63. Post SG.  Body. In: Encyclopedia of bioethics.
New York: MacMillan Reference USA; 2004a.
64. San Francisco LGBT Sangha. Dharma resources.
San Francisco LGBT Sangha. http://www.sflgbt-
sangha.org/dharma-resources.html. Accessed 8 Dec
2017.
65. Alipour M.  Islamic shari'a law, neotraditional-
ist Muslim scholars and transgender sex-reassign-
ment surgery: a case study of Ayatollah Khomeini's
and Sheikh al-Tantawi's fatwas. International J
Transgenderism. 2017;18(1):91–103. https://doi.org/
10.1080/15532739.2016.1250239.
66. Beemyn G, Rankin S. The lives of transgender peo-
ple. New York, NY: Columbia University Press; 2011.
67. Jizānī M b H.  Fiqh al-Nawāzil. Dammām, Saudi
Arabia: Dār Ibn al-Jūzī; 2006. p. 4.
245
68. Kanaan AM. Al-Mūsūʿa al-Ṭibbīya al-Fiqhīya. Beirut,
Libanon: Dār al-Nafā’is; 2000.
69. Kariminia MM.  Taġīīr-i Jinsīyat az Manẓar-i Fiqh
wa Huqūq. Qum, Iran: Intishārāt-i Markaz-i Fiqh-i yi
ʾAʾimma ʾAṭhār; 2010.
70. Kharrazi M.  Taġīīr al-Jinsīya. Fiqh Ahl al-Bait. No.
13. 1999:23–58.
71. Khomeini R.  Fatwā Taghīīr-i Jinsīyat. Retrieved
(March 2015) from: http://www.forum.mahtaa.com/
Thread-. 1987. ‫رییغت‬-‫تیسنج‬،-‫مالسا‬-‫و‬-‫لها‬-‫تنس‬.
72. Khomeini R.  Taḥrīr al-Wasīla. Najaf, Iraq: Maṭbaʿa
al-Ādāb; 1967/8.
73. Al-Khū’ī A. Fiqh al-A‘ḏār al-Shar‘iyya Wa al-Masāʼil
al-Ṭabbīya. Qum, Iran: Dar al-Ṣiddīqa al-Shahīda;
2006. Retrieved (December 2016) from: http://www.
alkhoei.net/ar/khlib/view/style1/196.
74. Kugle S. Homosexuality in Islam: Critical Reflection
on Gay, Lesbian, and Transgender Muslims. Oxford,
UK: Oneworld Publications; 2010.
75. Muntaziri HA.  Aḥkām-i Pizishkī. Tehran, Iran:
Intishārāt-i Sāyih; 2002.
76. Najmabadi A.  Professing selves: transsexuality and
same-sex desire in contemporary Iran. Durham, NC:
Duke University Press; 2014.
77. Qaraḍāwī Y.  Al-Ḥalāl wa al-Ḥarām Fī al-Islām.
Beirut, Libanon: al-Maktab al-Islāmī; 1980.
78. “Resolutions of the Islamic Fiqh Council-11thSession
1409HThe Sixth Fatwa Resolution on Change of Sex
from Male to Female and Vice Versa”. 1989. Islamic
Fiqh Council the Muslim World League. Retrieved
(February 2019) from: http://www.amjaonline.org/
fatwa-22813/info.
79. Sanders P. Gendering the ungendered body: hermaph-
rodites in medieval islamic law. In: Baron B, Keddie
N, editors. Women in middle eastern history: shifting
boundaries in sex and gender. New Haven, CT: Yale
University Press; 1991. p. 74–95.
80. Sarakhsī M b A.  Al-Mabsūṭ.Beirut. Dār al-Mʿarifa:
Libanon; 1993.
81. Shogo I.  Tackling sex re-assignment surgery in
Malaysia.New Mandala. 07 April, 2017. Retrieved
(Novemebr 2017): http://www.newmandala.org/
tacklingsex-re-assignment-surgery-malaysia/.
82. Skovgaard-Petersen J. Defining Islam for the Egyptian
State: Muftis and Fatwas of the Dār Al-Iftā. Leiden:
Brill; 1997.
83. Skovgaard-Petersen J. Sex Change in Cairo: Gender
and Islamic Law. J Inter Inst. 1995;2(3). Retrieved
(November 2014) from: http://quod.lib.umich.edu/j/
jii/4750978.0002.302?view=text;rgn=main.
84. Tabrīzī J. In: Husaini H, editor. Ahkām al-Muqtaribīn.
Tehran, Iran: Markaz al- Nashr Lī al-Majmaʿ
al-‘Ālamī; 1999.
85. Zainuddin AA, Mahdy ZA.  The Islamic perspec-
tives of gender-related issues in the management of
patients with disorders of sex development. Arch
Sex Behav. 2017;46:353–60. https://doi.org/10.1007/
s10508-016-0754-y.