By Katy Fulfer and Angel Petropanagos
At the recent FABWorld Congress in Mexico City, a panel on Ethics of Uterine Transplantation outlined three ethical challenges.
- Ariel Lefkowitz and Jacques Balayla, authors of the Montreal Criteria for Ethical Feasibility of Uterine Transplantation, suggested that only genetic females are suitable candidates for uterine transplantation, given the lack of non-human and human research trials on genetic males. However, the authors do not think that transwomen lack genuine desires to experience gestation, but rather, that the research needs to catch up before the surgery can be ethically offered to them. Indeed, uterine transplantation (in conjunction with other ARTs, like fertility preservation and IVF) can be important for helping both trans and cis women to satisfy their reproductive desires/achieve pregnancy.
- Timothy Murphy reviewed and rejected philosophical arguments that would discriminate against transwomen as candidates for uterine transplantation. Murphy argued for two significant identity claims: first, uterine transplantation is one way for a transwoman to physically affirm her identity as a woman. Second, uterine transplantation contributes to transwomen’s social gender identities in helping to “close the gap” between transwomen and ciswomen.
- Mianna Lotz raised concerns about the biological bias in favour of the gestational relationship (and in many cases genetic ties) that can unduly compel some women to choose uterine transplantation, despite the risks and uncertainties associated with uterine transplantation. (See Angel Petropanagos’ Impact Ethics blog post for a brief review of some of the medical and ethical challenges of uterine transplantation.)
The FAB panel on uterine transplantation provoked some important questions concerning the relationship between uterine transplantation, transgender women, and gender identity. We agree with Murphy that there is no principled reason to deny transgender women access to uterine transplantation, while permitting cisgender women to access to technology, provided that the procedure is medically safe and effective. However, we think that the relationship between uterine transplantation and personal and social identity affirmation warrants further examination.
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On the one hand, uterine transplantation may be one of many non-genital surgical interventions that are meaningful and important to a trans person’s sense of self (see the World Professional Association for Transgender Health‘s statement on medical necessity and treatment). Jay Prosser has argued that the movement from the pre-surgical body through gender reassignment surgery can be a significant for embodied identity. The body’s journey exemplifies the struggle for identity, a ‘rite of passage.’ It becomes a ritual which more completely affirms a person’s trans identity. We think Prosser’s claims could also be applied to uterine transplantation. Even though it is not visible in the way a reassignment surgery might be, it enables gestation, which is a significant symbol of feminine experience. So, uterine transplantation can be an important expression of feminine embodied identity for both trans women and ciswomen who lack a uterus. And, as Murphy pointed out, not only is uterine transplantation able to contribute to embodied identity for a transwoman, but it also builds solidarity among trans and cis women with respect to the possibility of this experience.
On the other hand the personal and social identities that are enabled by uterine transplantation are highly problematic because they are prone to promoting an essentialist view of women as reproducers. Essentializing women as (potential) reproducers in problematic because it compels some women to choose risky ART to achieve pregnancy and it reinforces social the stigmas against those who cannot or choose not to reproduce. In addition, women’s reproductive capacities (or gestation and motherhood) have been used to exclude women from public spaces and justify social and political inequalities.
While both trans and cis women may feel more like a real woman with uterine transplantation, that reality reinforces the idea that gestation is a central component of women’s experience and aligns with the pronatalist construction of maternal identity. Thus, closing the gap between cisgender women and transwomen, in this respect, does not challenge pronatalist forces with contribute to women’s social subordination. Although gestational experiences can be valuable, the personal choice to use uterine transplantation is inevitably political.
We are not suggesting that the affirmation of gender identity is wrong. Rather, we suggest that uterine transplantation reinforces a pronatalist characterization of femininity that is risky for women without a uterus to achieve via surgery. Furthermore, uterine transplantation, to some extent, contributes to the gender oppression of women as a group. To combat essentialist and pronatalist conceptions of femininity, women need safer reproductive options and just social structures in place, that make childbearing less onerous for women who choose it, and which do not discriminate against women who choose not to reproduce. For example, adoption could be promoted equally as ART as a means of family formation, and education and employment could be set up in ways that do not discriminate against women who are the primary caregivers to children.
In contrast to its essentializing potential, trans women’s uses of uterine transplantation may also open the door for challenging problematic essentialization of femininity; if uterine transplantation were safe and effective for genetic males, then perhaps cisgender men may consider receiving the surgery if their partners were unable to gestate. Such a possibility would not deny reproductive choice, but would destabilize the essentialist connection between women and womb-anhood.
Katy Fulfer is the Sophia M. Libman NEH Professor of the Humanities at Hood College with an appointment in the Women’s Studies Program and the Department of Philosophy & Religious Studies. She is also the book review editor for IJFAB.
Angel Petropanagos is a Philosophy Instructor at at Humber College and will soon be a Postdoctoral Fellow at Novel Tech Ethics at Dalhousie University.
This article really bothers me on a lot of fronts. Here are a few:
This is false: “The body’s journey exemplifies the struggle for identity, a ‘rite of passage.’ It becomes a ritual which more completely affirms a person’s trans identity. ”
Any of the possible medical aspects of transition don’t affirm one’s *trans* identity: they would affirm one’s gender identity (as, say, a woman). Those are two very different things.
But this is a very serious plea: don’t worry about the essentializing possibility. It’s not real. And if this distant possibility becomes a real worry for supporting research (or trans women’s access) to UTx, then that’s a tragedy.
Honestly, I don’t have much interest in UTx. Most of the trans women I know don’t. Some do. This is *not* something worth taking seriously as a concern. And, honestly? It really pisses me off that there’s as much focus here as there is.
Also: “In contrast to its essentializing potential, trans women’s uses of uterine transplantation may also open the door for challenging problematic essentialization of femininity; if uterine transplantation were safe and effective for genetic males, then perhaps cisgender men may consider receiving the surgery if their partners were unable to gestate.”
Wait wait wait. Who’s the “genetic males” we’re talking about? Do they mean trans women? Do I really have to explain how empty “genetic male” is as a category, and also how deeply offensive and oppressive calling trans women “genetic males” is?!
(For some reasons, see: http://www.autostraddle.com/its-time-for-people-to-stop-using-the-social-construct-of-biological-sex-to-defend-their-transmisogyny-240284/)
Rachel, thank you for your comments. Below we’ve clarified some points to further our discussion, as we share some of the concerns you raise in your response.
You seem to disagree with our reference to Jay Prosser’s work, in which Prosser makes the claim that reassignment surgery affirms a person’s identity as trans. He also argues that reassignment surgery can affirm one’s gender identity as a woman or man. It may be the case that Prosser is wrong about gender reassignment surgery, or that if Prosser is correct that we cannot make the analogy with uterine transplantation. However, it may be the case that sex reassignment surgery and/ or uterine transplantation surgery can be an important part of gender affirmation for some people. And, similarly, Prosser himself, does not think that all trans persons will feel that sex reassignment surgery is trans-identity affirming. Although we cannot make a full defense of Prosser’s claims here, Second Skins is a great read and we encourage everyone to check it out.
Sex and gender come apart: We believe that [a] both sex and gender are socially constructed categories, [b] they each are something like spectrum concepts or, as Anne Fausto-Sterling has suggested, non-linear “points in a multi-dimensional space,” and [c] biological sex markers have no necessary connection to gender identity. By “genetic males” in the last paragraph we were not making any attributions about gender identities. Rather, we were referring to the set of individuals who are excluded by the Montreal Criteria as candidates for uterine transplantation. That set of people would include at least some transwomen and at least some cismen, and our point was aimed at cisgender men whose potential use of uterine transplantation could potentially challenge essentialist views of womanhood. We believe we are closer in agreement than it may appear: that uterine transplantation does not necessarily or entirely essentialize women, but (as we say in our original post) has the potential to further destabilize the alleged connection between sex and gender classifications that social institutions assume come together.
We agree that in terms of prioritizing resources to improve access to and quality of trans persons’ healthcare, uterine transplantation is not at the top of the list. We should add that we do not think that uterine transplantation is a priority for other women’s healthcare as well.
About essentialism, we want to emphasize that our concerns about (or analysis of) the relationship between uterine transplantation and gender identity (or perhaps also maternal/ parental identity) can be applied to any case of human uterine transplantation, not just that by trans women. Our interest is really in how womanhood is constructed and reinforced within patriarchy, such that some women are unduly compelled into choosing risky procedures, like uterine transplantation, as a way of affirming their identity as a ‘real’ women. This essentializing notion of womanhood that squares women with reproducers is really what we find worrisome, for a bunch of reasons that we won’t elaborate on here, but with which feminists are generally familiar.
THE MORAL EFFECTS OF UTERUS TRANSPLANTATION
Timothy F. Murphy
The ultimate goal of uterus transplantation (UTx) is to offer women with absolute uterine infertility the possibility of gestating a child.(1) In the wake of recent clinical developments to secure this possibility for genetic women, some commentators have wondered whether transgender women might also be candidates for uterus transplantation (UTx), or even men. I have argued that there is no moral reason to exclude transgender women from UTx, should a focused line of research put that possibility in reach for them.(2)
Katy Fulfer and Angel Petropanagos say they agree that there is no principled reason to deny transgender women access to UTx, should it become available for them. They do say, however, that “the relationship between uterine transplantation and personal and social identity affirmation warrants further examination.”(3) Among other things, they say that UTx stands to contribute to the gender oppression of women. These commentators overstate the significance of the concerns they raise, for the reasons I describe below.
THE FORETOLD EFFECTS OF UTX
Fulfer and Petropanagos argue that UTx will both undercut the idea that gender is a matter of essences but also shore up the idea that gender is a matter of essences. They are more worried about the latter effect than they are happy about the former.
Fulfer and Petropanagos say that if it enables men to gestate, UTx would destabilize fixed ideas of gender: Gestation would no longer belong to women alone; indeed it could no longer function as a defining property of women. Fulfer and Petropanagos also note that UTx would “contribute to embodied identity” for transwomen but also build “solidary among trans and cis women.” Over and above simply pointing out these effects, Fulfer and Petropanagos offer no comment on their relative value, but given the rest of their commentary – with their emphasis on undoing essentializing accounts of women – I suspect they could only welcome the effects.
Even so, they appear to think that this de-essentializing effect is no offset to all the ways in which they think UTx would re-essentialize the supposed nature of women. They say, in fact, that that UTx is “highly problematic” for the women – transgendered and otherwise – who would pursue it. But mostly they worry about its effects for women as a class, worries that culminate in the judgment that it to some extent “contributes to the gender oppression of women.”
How is UTx oppressive for women as a class? Fulfer and Petropanagos list a number of predicted outcomes from turning to UTx as a means of identity formation, namely turning to UTx to fulfill expectations of gender. They say that UTx under these circumstances: (1) promotes an “essentialist view of women as producers,” (2) has effects that “compel some women to choose risky ART to achieve pregnancy,” (3) “reinforces social stigmas against those who cannot or choose not to reproduce,” (4) produces a feeling of “real” womanness which itself “reinforces the idea that gestation is a central component of women’s experiences,” (6) aligns “with the pronatalist construction of maternal identity,” and (7) “does not challenge pronatalist forces which contribute to women’s social subordination.”
Together these effects would conceptually confine all women to a certain social role, if not also a perceived nature, while also exposing the women who undergo UTx to the actual risks of the medical interventions involved. Despite identifying all these objectionable effects, Fulfer and Petropanagos nevertheless conclude – as I mentioned – that that no argument succeeds in principle against UTx for transgender women or other women.
Yet they still deem the effects listed here as “highly problematic.” But if these effects really are highly problematic, how do they not rise to the threshold of being an objection in principle to UTx? In fact, I think that Fulfer and Petropanagos overstate the significance of the possible outcomes they identify. UTx is in many ways no more significant than other kinds of assisted reproductive treatments (ARTs), relative to these outcomes. Whatever unwanted effects UTx might have, its effects must be weighed against the advantages it confers on women who want the experience it makes possible.
MORAL EFFECTS OF UTX
After listing objections to UTx, Fulfer and Petropanagos suggest social values and social practices that would offer more benefit to women than UTx. I will mention them only to ask whether UTx can coexist alongside those values and policies. Fulfer and Petropanagos say that “To combat essentialist and pronatalist conceptions of femininity, women need”: safer reproductive options, just social structures that make childbearing less onerous for women who choose it and that do not discriminate against women who choose not to have children, promotion of adoption on terms equal to ART as a means of family formation, and education and employment set up “in ways that do not discriminate against women who are the primary caregivers to children.”
Some of these options and social practices do not seem any less susceptible than UTx to the charge of presupposing and reinforcing pronatalist expectations of women and reductive ideas of their nature. For example, how is the restructuring of the workplace to make child-bearing a better option for women than it is at present, any less pronatalist than offering women with absolute uterine infertility the prospect of gestating their own children? How is the restructuring of education to integrate it better into the lives of women who choose to have children not also pronatalist in its own way? For all Fulfer and Petropaganos know, the restructuring of education and employment “in ways that do not discriminate against women who are the primary caregivers to children” might have more total pronatalist effect than the surgical option of UTx for the comparatively small subset of women, transgender and not, who might want it and the even smaller subset of people who might be situated to go through with it. Moreover, how is the call for safer reproductive options not also in its own way an inducement for women to have children? How are safer reproductive options not also entirely in alignment with pronatalist constructions of maternal identity? The lines are very blurry between efforts to enable women to have children and efforts to protect them from the idea that they must have children as some kind of gender fulfillment.
I also wonder how Fulfer and Petropaganos can be as confident as they are in the claims that UTx will produce identities “that are prone to promoting an essentialist view of women as reproducers.” Or that UTx will “reinforce social stigmas against those who cannot or choose not to reproduce.” What’s the evidence for predicting any such effects? I do not deny that UTx is conceptually consistent with the view that women should have children, but how do we know that UTX would be causally complicit in promoting or reinforcing any broad social presumption about the essence of women? Or that the effect of UTx would be more significant here than the effect of assisted pregnancies in general? Or that the effect of UTx would be more significant in this effect than the totality of unassisted pregnancies, which vastly outnumber assisted pregnancies? Like some of the other issues on Fulfer and Petropanagos’s list, this predicted effect in its causal aspects – that UTx promotes an essentialist view of women as reproducers – is ultimately an empirical matter, and as an estimation of the actual scope and significance of many of these predicted effects it would have to wait on the actual facts linking clinical theory and practices to demonstrable social effect.
MORAL CAUTION
At best, the concerns that Fulfer and Petropanagos raise show only that there are reasons to be cautious about the practice of UTx. UTx must involve exposure to risk, but that exposure will have to be assessed relative to the expected benefits of the transplantation, an assessment carried out first and foremost by the women considering this kind of transplantation now, and by transgender women later if that prospect comes to pass. Above all, a rigorous practice of informed consent is implied in any move toward UTx, as is morally requisite in any significant body modification. The obligation of informed consent will also, of course, apply to women who step forward to act as living donors of uteruses. Their exposure to risk has for them, no compensatory medical benefit, but it might have important psychological significance as the counterbalancing benefit.
Fulfer and Petropanagos also link UTx to concerns about the social and moral understanding of women – and their relationship to children – but their worries about UTx seem overstated in terms of predicted social effects. Even if UTx is successful in securing gestation for women, its cost and complexity will put it beyond the reach of most women. Its actual social meaning – whether it will (further) reduce women to a gendered essence – can only be assessed in the light of its actual social reception. I will also say here that when it comes to assessing effects of UTx, Fulfer and Petropanagos understate the liberatory value of UTx, if gestation can be uncoupled from genetic women and extended to others. What better way to de-essentialize women in their reproductive role than by – eventually, possibly – opening up the prospect of gestation to men?
I do not find UTx to be “highly problematic” in its aspirational goals or in its foreseeable social effects. Some women value the prospect of gestation for various symbolic, psychological, and familial reasons. Those aspirations seem reasonable on their own, without having to view them as colonized by objectionable views of women’s natures. As to the likely effects of UTx, some of the practices that Fulfer and Petropanagos call for as a pathway to a less pronatalist, less essentialist view of women, do not seem undermined by UTx. Restructing the workplace to make childbearing easier for women is not undone by efforts to perfect UTx. In any case, uterine transplantation will always remain a costly and complex pathway to gestational motherhood. Its effects in transforming expectations of women is likely to be far less important than other social influences that shape expectations of what women really are and what their responsibilities really are in relation to children.
REFERENCES
1. Ariel Lefkowitz, Marcel Edwards, Jacques Balayla, “The Montreal Criteria for the Ethical Feasibility of Uterine Transplantation,” Transplantation International. 2012 (25): 439-447. See also Ariel Lefkowitz, Marcel Edwards, Jacques Balayla, “Ethical considerations in the era of the uterine transplant: an update of the ‘Montreal Criteria for the Ethical Feasibility of Uterine Transplantation,” Fertility and Sterility 2013 (100): 924-926.
2. Katy Fulfer and Angel Petropanagos, “Does a Womb Make you a Woman,” Feminist Approaches to Bioethics Website. July 9, 2014. At: http://www.ijfab.org/blog/does-a-womb-make-you-a-woman/. Their analysis is a response to a panel discussion of presentation on the topic of uterus transplantation, at the Feminist Approaches to Bioethics conference, Mexico City. Their commentary describes certain aspects of presentations by Ariel Lefkowitz, Jacques Balayla, and Mianna Lotz, and myself. I focused on the possibility of uterus transplants for transgender women.