1. The separation between sex and gender: the emergence of gender studies

What is the constitutively human, nature or culture? In other words, is sex understood as given by human nature and, therefore, fixed and immovable, or the gender, which is the product of human creativity and freedom, that shapes the field of the cultural, therefore, changeable and porous? This seems, to be the question that denotes various answers ranging from irreconcilable positions, to some more centrist, in any of them, the subject necessarily goes through the categories of «sex», «gender» and the intrinsic relationships that they establish in the field of knowledge and power.

These categories and their derivative relationships are the subject of serious studies and deep reflections in our time, thus, there emerge concern about gender studies, the commitment to the liberation of women and the forms considered subversive of sexuality, that is, gays, lesbians, bisexuals, transsexuals and transgender people.

From the work of Simone de Beauvoir, The second sex, where it is stated that «a woman is not born, she becomes a woman» (^{Beauvoir 2005, p. 109}) to the studies of Michel Foucault in his History of sexuality in 1979; the underlying debate between the two categories has revealed the power play that is exercised under naturalistic arguments. In the debate where the fact is taken for granted and valid that certain characteristics correspond to each nature and that, by definition, those of women have been the most «weak and incomplete». Then consequently, the place that it has occupied in the relationship with men has always been inferior for belonging to the «weak sex», being subjected to a dominance and control by men, and reduced to the functions that are «inherent» according to their sex.

From the foregone study of these two categories in both authors has underpinned the awakening, on the one hand, of women considered historically inferior and, on the other hand, a radical questioning of the indissolubility between the naturally given and the socially constructed. Thus, the idea of understanding that although there may or may not¹ be a biological basis for determination as a woman or as a male arises. This determination is separated from behavior, practices, ways of being and actions that the person can execute. These were called «gender» and it was established that it depends on social constructs and, therefore, is modifiable and variable.

So then, «sex» and «gender» meant two different things -if not opposite. Sex comes from nature that in turn represents the field of determinism because it is fixed and immovable, and can only be in the person either female or male, establishing a radical difference between the two that constitutes the pre-cultural episteme that determines and permeates social relations and justifies the power relations between the two mentioned sexes. For its part, gender will be the residue of social constructs, of cultural spheres that can be varied and heterogeneous, so the range of possibilities is no longer only binary but multiple: from the feminine or the masculine, the relationship between the sexes is admitted, admitting the homosexuality, heterosexuality, bisexuality, transsexuality, etc.

Gender is no longer the field of determinism but of the freedom and creativity where behavior no longer depends on what nature marks but on the ways in which social relations, laws, and the customs are being configured, and that they are permeating in different forums and public spaces. Gender is the relationship and the power that is exerted between and through the bodies, they are the asymmetric relationships that find their foundation in prejudices and social constructions and, therefore, lack strength and soundness.

Gender is then understood as: «the socially constructed roles, behaviors, activities and attributes that a society considers appropriate for men and women» (^{WHO, 2019}).

Some examples that illustrate the idea of gender as a social role are to think of the figure of the male as the provider of care and livelihood. It follows that he necessarily has the last word; who must give orders to the woman; who must go to work; the one who must obtain positions of authority in professional life; the one who must be physically stronger and devotes himself to the work considered «heavy». While the woman must be the one who takes care of home, the children, the one who should not work, which should be dedicated to cooking and cleaning, which cannot occupy positions of authority and must have a lower salary than the male, which represents the side of feelings and emotions and not the rational and/or logical, etc.

We must recognize that the first gender studies gave rise to the first generations of feminists (^{Bonder, 1998}). Their basis lay in the vindication of the rights that had been denied to women only because they were women. This criticism provoked very favorable ideas for the understanding of human nature as a principle of maximum respect and promotion of the person. The discussion not only made publicly appear the shame of acting according to customs and customs without ensuring the integrity of human dignity but also historically placed the fact of the social vulnerability that marginalizes and excludes without foundation, so his voice represented an impossible milestone to keep silent.

With this, it is necessary to differentiate between the gender studies that perform the task of analyzing and studying the fact of the relationships between the sexes in an objective and methodical way and the gender ideology that derives from the defense of gender equality. The historical inequality is perceived and defends the free choice of the uprooted gender of sex and the so-called gender perspective that attempts, under academic, political, institutional practices, to alleviate the existing inequality between the female sex and the male sex with the objective of making equally worth the dignity of both as people. In the words of Burgos: «I understand as a gender ideology the theoretical perspective of radical cut that conceives sexuality as a personal choice on a biological background» (^{Burgos, 2011}).

Likewise, it is pertinent to clarify some notions that result in this study and that have been promoted because of the separation between sex and gender. It has been already clarified that sex will be given by the chromosome combination resulting from the 23 chromosomes of female gametes, and the 23 chromosomes of male gametes, being able to result in a «XX» as a female (female), and an «XY «as male (male). We may consider the many variables that the fetus is susceptible throughout its development. Considering the hormonal loads to which they are subjected to (chromosomal and phenotypic sex), and thus, the gender understood as the roles and behaviors that are expected for both, then, we can distinguish in the first place the sexual identity as that differentiation between the body of the person and his psyche. The psyche is the one that generates emotions and feelings of self-belonging and identification and recognition of himself and, therefore, of agreement between what he feels he is and what he really is.

In the previous notion, you can find identification problems of men who have the body of men, hormonal load of men but who «feel themselves» as women or vice versa.

2. Vulnerability

To speak about vulnerability is to appeal to the very essence of the human being; it is, therefore and before any subsequent affirmation, an anthropological condition of the human being.

The human being, then, carries, in itself, the indelible mark of his vulnerability, that is to say, being a finite substance, he dies and, as Pascal says, not only dies but knows that he dies (^{Pascal, 2003}). Thus, his life becomes a struggle for survival because its existence is so short that it can be subside at any time and under any circumstances. Sickness, pain, suffering, the experience of human contradiction itself and of life as a project, as something that has not been done previously, constitute combining elements of its own vulnerability.

Therefore, it is necessary to speak, in a first instance of the anthropological vulnerability for, in a second stage, to connect it with the social vulnerability from where bioethical reflection emanates.

To speak of vulnerability is to appeal to the very essence of the human being; it is, therefore and before any subsequent affirmation, an anthropological condition of the human being.

The human being, then, carries, in itself, the indelible seal of his vulnerability, that is, by being a finite substance, he dies and, as Pascal says, not only dies, but also knows that he dies. Thus, his life becomes a struggle for survival because its existence is so short that it can be shortened at any time and under any circumstances. Sickness, pain, suffering, the experience of human contradiction itself and of life as a project, as something that must be done because it was not previously, constitute amalgamating elements of its own vulnerability.

For Francisco J. De la Torre, there are four columns of vulnerability: fragility, nudity, the possibility of contempt and weakness (^{De la Torre, 2017, 155}).

Fragility refers to the damage that can be done and that we can suffer depending on our space-time condition, as Feito affirms: «the human being, who can be hurt for being fragile, and who is not only hurt but also marked because of the scar, memory of pain, he is a victim of his own mortal condition» (^{Feito, 2007, p. 9}).

On the other hand, the nakedness is the state of total defenselessness of the human being but, at the same time, it is the state of greatest request for ethical responsibility since it prevents being indifferent to the suffering face of others, because their nakedness is a sign of their authenticity³ (^{Levinas, 1974, pp. 55-56}).

In this regard, the third characteristic of human vulnerability, the possibility of contempt, necessarily appeals to the recognition of oneself, that is, to the possibility of encountering those who present themselves as fragile and vulnerable and that resemble the characteristics of fragility and vulnerability and, therefore, becomes a mirror of oneself (^{Taylor, 2001, p. 55}).

Finally, the weakness that puts us in a situation of «falling», meaning of being defeated, injured, hurt, of failing, of not complying, of making mistakes and even of hurting others. It rests on what Ricoeur has called lability, and that it is based on the ideal of infinity and the finite reality that we are. This unfulfilled yearning causes sadness and frustration to the human being, for not being able to achieve what he wants (^{Calvo, 1991, p. 97}).

These qualities represent the concept of anthropological vulnerability that admits that we are all vulnerable in terms of our humanity and our ability to be hurt or injured, either bodily, or morally, psychologically or integrally.

It must be remembered that the ontological condition of the person goes hand in hand with the action remarking that human dignity is reflected in human actions, (it is not reduced to these but is reflected in them by the human dynamism of the action ) therefore, in the construction and conquest of freedom. Thus, freedom is no longer just a quality but a capacity that, in order to be exerted requires, in turn, the necessary agency.

The awareness that our life is a project and this puts us in a vulnerability constant because weakness, nudity, and fragility that threaten this life project, can occur. Thus, the paradox of the human being arises in that he knows himself worthy and free but at the same time vulnerable and threatened by his environment and by others. Feito affirms: «Intrinsic anthropological vulnerability is, then, not only an affirmation of our helplessness or weakness, but, rather, a finding of life as a task, as something to be built, from our radical finitude» (^{Feito, 2007, p. 10}).

In summary, anthropological vulnerability implies, on the one hand, the same fragile and deadly condition of the human being but, at the same time, the relationship with others and their environment, the ability to exercise their freedom and forge their identity; because of this, social vulnerability arises.

Social vulnerability comes from the essentially relational being of a human being as Aristotle claimed (^{Aristotle, 2011, Book II 1253a}).

As stated before, being in the world already implies having to deal with the world, that is to say, necessarily I am and I act with the other thing, and with others and in this impact received from others I am influenced by them and by the environment. In this way, there are conditions or circumstances that put me at a greater risk of being affected by them, and if they have already added by themselves, a vulnerable anthropological condition, then the risk is twofold and the affectation is superior.

The surroundings and the environment, the historical situation, the purchasing capability of people, the laws of the market, the culture and geographical composition of a place, the climate, the availability and accessibility of resources and even the prevailing prejudices and beliefs, constitute factors that can harm people. Some people call this double possibility of being hurt or injured «spaces of vulnerability» (^{Feito, 2007, p. 11}), being conditions that expose the person not only to a greater risk but also place them in a degree of greater difficulty in defending themselves or in looking after themselves.

It is necessary to point out here, that the degree of vulnerability of a person can be increased in that there are risks over which there is no human control, and they hurt the person. If the person has historically lacked the means to overcome these adverse conditions, his/her vulnerability is increased with axes in a triple dimension: the anthropological vulnerability (typical of every human being), the social vulnerability caused by external situations that are beyond human control, and the social vulnerability produced due to the lack or shortage of resources (physical and material, psychological and even legal) to overcome the risk.

In this way, social vulnerability can be classified as external, formed by the triggers of a crisis, some of which, such as natural disasters, are out of human control. There are others, that fall under human control - and which are the ones that later on, we will be more interested in their reversible character - such as marginalization and social exclusion, genocides or migratory flows due to situations of war or forced displacement. Nevertheless, there are also internal factors that deal with the ability to overcome external factors and these have to do with the conditions of social justice of each human group. Hence, there are human groups that, having historically lacked moral or legal recognition, are more exposed and vulnerable to defend themselves or get ahead of adverse situations. In these, the level of vulnerability is much higher. This occurs, as we will see below, in the groups that have adopted the gender ideology as constitutive of their being and their actions.

3. The ideology of gender as a social vulnerability: the analysis from Bioethics

In the first section of this chapter, the origin of gender ideology was discussed as a residue to the philosophical discussion detached from the notions of «gender» and «sex» but fueled by the categories of «culture» and «nature». In this section, we will give some guidelines that want to argue how gender ideology has been the cause of a greater exposure to the vulnerability of certain human groups such as the LGTBI+ collective.

In the first place, by separating the biological basis of sexuality from the integrity of the person as a unit, gender ideology⁴ marked an absolute freedom for the person, so absolute that it is exposed to desires and inclinations as temporary as passing are the emotions that we human beings experiment daily.

Thus, placing the person at total shortage of fundamentals, and locating it as a being in constant construction but without neither biological nor identity roots, allows a de-dignified conception of it, that is, places it in the plane of the rest of the entities who do not have a need to function in the world and deal with reality. He places it as a reality closed and turned towards himself but, also therefore, exposed to what others want to do with it.

The material entities, become tools to the extent that it is the human being who gives them the meaning of their existence. This is because they have a meaning or even less, a vocation to become useful, but because they are so for the human being and, opposite to this one, its essence is closed and subject to what others decide about her.

On the other hand, the human being is a realities being (^{López Quintás, 2000, p. 36}) who builds up his world and builds on his actions; it is a being that participates in and with others in the construction of his own reason to be and of the sense of being for the others (^{Gevaert, 2001, p. 14}). This is why we cannot decide for others, because each one is a substantial unit with a capacity for its own reasoning and, therefore, of his own choices. Our essence is not one already given and prefixed by another but it is a mystery (^{Gevaert, 2001, p. 14}). It remains in constant change and reification to the extent that we are being affected by others; nevertheless, this advent is not infinitely open either but always falls on that individual substance that we are each one of us and over which we are accepting to be modified by the environment or not. Always in reference to what each one is even before interacting with the world.

Now, if it is stated that the person does not have a task to do through his freedom and his judgment, then the meaning and the horizon of reality upon which our decisions rest is lost. By losing this horizon, the person attends the collapse of its intrinsic value thereby rejecting any possibility of livelihood. Thus remains its existence reduced to a mere existence, to the realm of beings that do not have freedom and do not need to have it either.

By suggesting this lack of ontological foundations, which would allow the exchange of content without altering the own essence of each person, and by not having to form their being nor forge their identity based on something, gender ideology permeates the most intimate structures of people granting them an assumed freedom to choose their gender and act accordingly. The foregone leaves people exposed to social factors of recognition that do not always end up being as such. In this way, the degree of vulnerability increases because people do not have, for the most part, the mechanisms that provide them with the capacity for their own defense.

The LGTBI+ groups evidence the foregone where a frontal struggle has been established for the defense and recognition of their rights. However at the same time, those groups have been systematically not recognized and even violated, even it would seem that the greater their cause, more types of violence⁵ afflict them. All the above as a function of their demand of a special attitude just for the fact of being LGTBI+, but not for the fact of being people and at the moment of particularizing rights, the mechanisms to defend them also cease to be accessible to all and they adapt to particular groups generating a greater deficiency to their accessibility.

LGTBI+ people have no rights for being such, but for the fact that they are people. Well now, remembering what was previously stated about the three dimensions of vulnerability, an LGTBI+ person is a vulnerable person. Firstly because he/her is a person and for its human condition; secondly for the social factors which increase exponentially his/her vulnerability, either for the life circumstances of each one or else for the social prejudices that exist around those who declare themselves homosexual, bisexual, transsexual, etc. The scope of concealment and secrecy encourages their risk behaviors and harbors greater vulnerability for them. Thirdly, on multiple occasions, due to the second vulnerability already explained, they suffer harassment and contempt, ill-treatment and social exclusion and lack the means to report or defend themselves, since also due to existing prejudices and beliefs, forces them to come out of hiding and this, is in turn, is also, to assume a higher risk.

Therefore, the claim of their rights and, moreover, of specific rights for them, focuses on requesting recognition that provides them with the necessary means to get out of hiding without risks and / or threats.

While it is true that not all LGTBI+ groups proclaim and defend the gender ideology, it is also true that it does not strengthen but radicalizes their requests.

The gender ideology in rejecting the ontological basis of the person as a woman or male has proclaimed, in turn, many «ontologies» that make believe that it is necessary to emphasize many recognitions leaving their proper development to the extent that these recognitions are given. In fact, this is to make the dignity depend as intrinsic value of every person on regulatory conditions, that is, on negative actions.

With the foregone, the subject remains in a state of greater vulnerability since, if his condition is not recognized, his «ontology» is unsatisfied and more easily damaged.

The recovery, therefore, of the ontological substrate of the person together with its full recognition would affirm not many, but a single ontology and not dependent on social factors. The gender ideology, in an effort to defend an autonomy and mastery of nature, exposes the person more to areas of reality that make their already marked vulnerability even greater.

In this way, affirmative actions that not only repair the damage of non-recognition but also provide the person with the tools to defend and overcome itself, necessarily imply recognizing the dignity of each person as such, not as their categorizations. Thus, the homosexual must be recognized not because he is homosexual but because he is a person, the path must go to the side of the return to the person and the assumption of an ontological substrate in each one.

Many have been the consequences of the gender ideology in Bioethics issues, mainly due to the practices where the person is exposed to greater degrees of vulnerability because they involve invasive procedures and that pose high risks to the life and health of the person.

An example of how gender ideology exposes the person to greater vulnerability, are the gender-reassignment surgical interventions from which it is possible to discuss the therapeutic principle.

From the bioethics, the therapeutic principle is considered as the one that allows an intervention action on a part of the person’s body in order to preserve the whole and as long as there is a necessary condition to intervene. It is addressed of medical necessity when, in case of not intervening, the person’s life is in imminent danger and he or she may even die. Thus, the therapeutic principle implies assuming the risks of a surgery or of a procedure for the benefit of the whole, the highest good premium in the decision.

However, sex reassignment or sex-generic agreement surgeries, requested and permeated by the growing gender ideology, have as a basis to «match» the biological sex of the person with the gender the same has assumed. Chárries Cordero defines them as:

«Sexual reassignment surgery (SRS) consists of surgical processes that women and transsexual men carry out to harmonize their anatomical sex with their sexual identity. It can focus on the genitals, called genital reconstruction surgery, and in which operations such as vaginoplasty, metadoioplasty or phalloplasty can be distinguished. But there are also feminizing or masculinizing operations of non-genital sexual characters, such as facial surgery or mastectomy» (^{Chárries, 2013, p. 24})

Thus, except in cases where a pressing and urgent need has been diagnosed where it is considered that the person’s life is in danger, these surgeries should be carried out since the risks of these surpass the benefits obtained.

The simple fact of presenting a sexual identity different from that naturally oriented by biological sex may be due more to fashions and normative social discourses in historical times than to true causes of psychological disorders that may endanger the physical or mental health of the person.

It is worth mentioning that there is a gender identity disorder or gender dysphoria⁶ and that it does occur relatively frequently among the population. Even criteria for the inclusion of patients in sex change surgeries have already been established (^{Pavon, 2000, p. 783}) since it is considered that this disorder if it affects the mental health of people more should not be confused as any request to express it so.

In addition to the therapeutic principle, the principle of integrity that would imply a requirement to respect the place of manifestation of the person, which is his body, and safeguard its values and preferences in accordance with this should be assessed. Thus, by intervening on a person’s body, it is being intervened on its integrity as such and, if they do not assume this position, it could remain irreversibly damaged.

Some other forms of vulnerability that people are subjected to when accepting sex-gender separation in the field of health include: faults in due informed consent assuming they are inferior or unable to make decisions, ill-treatment and / or teasing by medical personnel, forced sterilization practices, non-consensual hormonal treatments, etcetera.⁷

A bioethical approach would need, in addition to reviewing the conditions of the therapeutic principle, to analyze the issues related to informed consent that turns out to be an area that exposes patients to greater vulnerability by not giving them access to accurate and truthful information about their condition and possible existing treatments. It must be remembered that informed consent must be provided by law in all invasive procedures which involve health risks, and in family planning issues. Failure to give information or give it in a fragmented way is to incur in a serious ethical fault. In the matter at hand, informing about the differences between sex and gender but also, about the continuity of these concepts implies assuming the ontological condition of the person as a sexed being and its manifestation as a man or as a woman (^{Burgos, 2011, p. 9}) without necessarily having to contravene these notions.

Let us remember that gender ideology is not gender theory as explained at the beginning of this chapter and that, on the contrary, it is more a residue that is situated in the radicalization of natural and social separation than in the theoretical foundation of the notions. Thus, in some way, this understanding contributes to noninformation and, in health matters, to the lack of informed consent in the professional relationship of the patient-health by placing it in a greater degree of vulnerability.

Conclusions

Bioethics has a transcendental role, especially in relation to vulnerable groups and vulnerable people. It must set the guidelines and actions necessary to try, firstly to recover and level the conditions that initially put that person in greater exposure and, secondly, ensure that this person has the mechanisms that allow him, in terms of facing his life and overcoming the obstacles that life presents to it.

Moving from responsibility to solidarity is essential if we want Bioethics to attend and improve unfair and unequal conditions. The fair and solicitous attention of the fragile and needy constitutes an urgent cry for ethics and bioethics, even more so, when there are ideologies that continue to insist on leaving the human being devoid of a firm and unalterable ground and subject to the variables of the social environment where prejudices and marginal ideas prevail.

For all the above, it is imperative to address the sex-generic dualism from a compassionate bioethical view that corrects but embraces, which is capable of revealing the truth of the human being in the light of empathy and solidarity support, not by virtue of necessary care, but by virtue of the recognition of our common vulnerable human condition.