This blog is about a topic that I only recently discovered, though an important voice in the dialogue about transgender activism and women’s rights mentioned it earlier this year.  

I do not recall how I first stumbled upon this small – but growing – corner of scientific literature. When I first discovered it, it stirred me up so much that I knew I had to write something in response.

I initially thought I’d write a letter to the editor of the journal, but of course academic publishing has myriad constraints and rules. Here in my own corner of the web, I can freely oscillate between emotional reactions, scientific facts, and gut wisdom in my response. 

The topic is uterine transplants in males.

Let’s back up.

 

In 2014, for the first time ever, a baby was born from a woman who received her mother’s uterus as a transplanted organ. As you might imagine, uterine transplants are very complicated, even as far as organ transplants go.

For example, during pregnancy, the uterus receives 20 times more blood then it does in a non-pregnant state. A transplanted uterus cannot be connected up to all of the arteries that a naturally-occurring uterus is connected to, and this creates pregnancy complications through insufficient blood flow.

This woman did develop pre-eclampsia, which can result from insufficient placental invasion and corresponding reduced uterine blood flow, so the baby was born by c-section several weeks early.

Shortly after this stunning surgical success story, people started wondering if such a surgery – and subsequent pregnancy – could work in male bodies (example; example; example).

 

The idea of males gestating has roots in science fiction as well as in what has been dubbed ‘medical-industrial capitalism’.  A general increase in transgender visibility and activism – much of which is unfortunately funded by the pharmaceutical industry - has shifted the conversation from a strange fantasy to a potential reality.

 

To be very clear, let me say I absolutely oppose uterine transplants into males, regardless of what the man’s gender identity or expression might be. I especially oppose uterine transplants into males that have the desired outcome of gestating offspring.

 

Inserting uteri into male bodies with the intent to gestate and birth offspring is an aberration of the process of reproduction, one I vehemently oppose on instinctual, spiritual, emotional, and scientific grounds. The possible outcome of such a Frankenstein-esque process on the fetus cannot be scientifically ascertained in an ethical manner, which should, in a sane world, preclude this from even happening. One might argue for the use of animal models of male pregnancy to test for negative effects on the developing fetus, but human pregnancy is very different than other animals, due largely to highly invasive placentation and large brains, so animal models are insufficient in this case.

 

My knowledge of evolutionary biology positions me to view female reproduction through a different lens than medical doctors and surgeons. Much of western medicine, including surgery, is grounded in reductionism - viewing the body as a set of parts that can be broken and fixed, removed and replaced. Evolutionary theory urges us to understand the female body as a bundle of tense compromises and tradeoffs that sensitively responds to its surrounding environment.

Transwomen are biological males who feel like women. They may experience intense discomfort with their male bodies and may seek out hormonal therapy and cosmetic surgeries in order to phenotypically resemble women. Such procedures can have the effect of reducing dysphoric feelings and bodily discomfort for some of these people.

Surgeries may include facial feminization surgery, breast implants, and the construction of a ‘neo-vagina’. A neo-vagina may be created from existing male genitalia (the penis and scrotal tissue is inverted to preserve sensitivity and sexual function). In another surgical method, intestinal tissue may be used to create a vaginal canal; this is a less desirable method, but necessary when there is insufficient genital tissue with which to build a vagina. 

Growing interest in uterine transplants suggests that hormones that feminize the appearance and surgeries that give the outer appearance of womanliness are no longer sufficient.

 

Some males wish to possess a uterus. Having a uterus installed in their bodies -especially one that bleeds and perhaps even one that gestates - would have “psychological benefits” and “play an integral role in the expression and consolidation of a female identity” (Jones et al., 2018).

This type of language highlights what the goal of these uterine transplants would be: to make the male (or transwoman) feel more like a woman.

Yet, people who align with this kind of thinking are frequently the same people who would argue that ‘not all women gestate’ and ‘not all women get periods’ and ‘not all women have a uterus’.

But now, having a uterus, a menstrual period, and the capacity to gestate is “intrinsically part of being female” (Jones et al., 2018) and thus, transwomen should get to have such an experience.

These reproductive capacities, exquisitely sculpted through eons of evolutionary time involving dynamic tensions between mother and offspring, male and female, are now the next frontier.

 

A uterus is a muscular organ that rests in the pelvic bowl of women. Connected to the ovaries via the fallopian tubes and closed via the cervix at the top of the vagina, the uterus is a remarkable organ that is in constant motion. Each month, provided a woman is producing certain quantities of ovarian hormones, the uterus demonstrates a capacity to shape-shift. The surface of the uterus (endometrium) proliferates under the influence of estradiol, which is secreted by cells surrounding the growing ovulatory follicle.

After the hopeful egg ruptures from its cocoon, the remaining cells form the corpus luteum and secrete progesterone, which orchestrates a fascinating suite of morphological and biochemical changes to the endometrial lining. The cells of the thickened lining become larger, form gaps amongst themselves, and secrete specialized cocktails of immune molecules. This lining is highly receptive to a fertilized egg; indeed, if the conditions are just right, the embryo will be attracted to the lush grounds of the decidualized endometrium and will embed itself into the uterine lining. If implantation does not occur, progesterone levels drop and the lining breaks down and the woman bleeds. Menstrual material exits the woman’s uterus through the cervix and then vagina. 

The system of the ovaries, fallopian tubes, uterus, cervix, and vagina, and associated hormones, work together to support ovulation, decidualization, implantation, gestation, menstruation, birth, and placental expulsion. Modulation of these processes extends far beyond the reproductive organs themselves, as these organs are the targets of hypothalamic and pituitary hormones that shift according to menstrual cycle phase, energy balance, as well as pregnancy status. The brain and the reproductive tract are in constant communication, adjusting hormone levels through positive and negative feedback.

 

What I’m trying to say through this brief and simplified overview is that female reproduction constitutes a complex system of interacting and mutually-dependent components. These components as well as their interactions are highly sensitive to a woman’s nutrition status, body weight, activity level, as well as environmental cues, such as relative safety or danger or social support.

 

The notion that you can simply remove a uterus from a woman and insert it into a male body has got to be the most perfectly aggravating example of reductionist biology I have ever encountered.

 

The notion that you can remove and insert organs like they are pieces of an engine or puzzle reflects a stunning disrespect for the functional integrity of the female body. This type of thinking and practice underpins medical interventions that damages females.

 

For example, if the uterus is not working, bleeding too much, or too painful, a surgeon might suggest its removal. Indeed, some women seek out hysterectomies to help treat the debilitating pain of severe endometriosis. However, removing the uterus from a woman has negative, far-reaching effects that are only beginning to be appreciated. Cognitive decline is one example.

 

 Let’s be reminded that women around the world suffer from genital mutilation, obstetric complications such as fistula (and ostracism after the fact), obstetric violence (eg. The ‘husband stitch’), infertility, exploitation via prostitution as well as gestational surrogacy.

 

I know it doesn’t work this way, but imagine if the time, creativity, and MONEY that went toward imagining how we might create bleeding, gestating males went toward helping women and their families navigate fertility, prenatal care, pregnancy, birth, postpartum care, and childcare.

 

I’ve found a number of researchers and articles exploring the ethical, legal, anatomical, hormonal, and obstetric challenges of implanting uteri in transwomen. l examine some of their ideas and claims below.

 

From an ethical standpoint, as I said above, all I require is a strong gut knowing that it is wrong and terrifying to attempt to alter the course of human reproduction in this manner. It is a blatant disregard for the mother-child dyad to experiment with other forms of gestating. As you can perhaps tell, I’m not much of a fan of ‘artificial’ wombs either.

 

A more objective ethical issue is that the desire for donor uteri could very well generate a black market for uteri. Women are already exploited for their sexual and gestational capacities.  

Furthermore, scientists write that donor uteri from living women function better than donor uteri from dead women (Jones et al., 2018). It is rather terrifying to think about what could happen when wealthy males and their scientifically-curious teams of doctors and surgeons might achieve, in terms of seeking out sources for women’s body parts.

Don’t worry though, the authors do offer a solution to this issue of organ sourcing.

 

Uteri could come from transmen (females who identify as men), provided these females are willing to risk a hysterectomy. Transplanting a vagina and cervix in addition to a uterus would be the optimal solution, according to Jones and colleagues, as this would solve several problems at once (more on this below).

If the general trend observed in organ donation as a whole continues, women will continue to be donors more often than they are recipients.

 

Would this mean that transwomen would end up getting uteri more than women with actual AUFI?

 

Oh wait – what is AUFI? Here is a stunning example of word trickery in the gender world.

 

AUFI stands for absolute uterine factor infertility. It is the anatomical absence of the uterus, due to its surgical removal or absence from birth, or the physiological inability of a uterus to sustain a pregnancy.

 

Jones et al. describe trans women (males who identify as woman) in the following way:

“Transgender women have AUFI, and therefore they cannot experience gestation, which may play an integral role in the expression and consolidation of a female identify, and is considered by many to constitute a transformative experience.”

 

Males cannot have AUFI because they do not have uteri, and were not ever intended to develop with one! This is a sneaky trick of language, that serves to somehow equate men without uteri (all males) to women suffering from infertility. Classifying transgender women as having AUFI paints them as victims of their biology, in the same way that infertile women may feel when they are unable to carry a baby to term. It is not the same, as women have a reasonable expectation of being able to get pregnant and deliver an offspring, whereas men have a reasonable expectation of being able to inseminate a woman and sire an offspring.

 

From a legal standpoint, unfortunately, years of gender ideology has infected legislation in several countries. For example, in the UK, on the basis of anti-discrimination gender laws, it might actually be illegal to NOT offer males uterine transplants, should they be proven to be doable. Yikes.

 

From a scientific perspective, I am rather unimpressed with the current attempts to outline the challenges of transplanting uteri into males.

 

The main hormonal obstacle to functional uteri in males is the absence of ovaries, which are important producers of key pregnancy hormones. Thus, if a male were pregnant (can’t believe I’m typing that), they would need a constant artificial supply of hormones.  

In a woman’s body, there is a delicate feedback between the embryo, placenta, ovaries, and her brain, but in a transwoman, a mixture of estradiol (which is already given for feminization) as well as progesterone (which maintains uterine lining) would need to be given. How much, in what combo, and what other hormones are not even mentioned in this article.

Anti-androgens, which are often given to trans women to reduce male-typical characteristics, would need to be discontinued as they would be toxic to the offspring. I do not think a doctor could reasonably mimic the complex and fluctuating hormonal mileu of a pregnant woman.

 

An anatomical challenge is the sex dimorphism in pelvic size and shape. Males have smaller pelvises than women. They do not have vaginas or cervixes, which form a closure and entrance/exit point of the uterus. Blood vessels of the pelvic region are larger in women than men, and substantially change during pregnancy to accommodate the growing fetus’ nutritional needs. The vaginal mucous also plays an important role in regulating the microbial uterine environment.

 

A surgically constructed vagina in a male body cannot support the necessary population of lactobacilli which is necessary for a healthy vaginal and uterine flora. Indeed women lacking vaginas due to a rare sex development condition who have had uterine transplants along with neo-vagina surgery are unable to sustain live births, according to Brännström, an expert in the field.

 

Don’t worry though - the authors also have solutions to these challenges!

 

A ‘solution’ the authors suggest, regarding the smaller bony pelvis of men, is to start transitioning boys at younger ages. If boys stop male puberty with hormone blockers (which are known to have various negative outcomes) and are then given exogenous female hormones, then perhaps their pelvises will grow large enough to someday accommodate a fetus in their future transplanted uterus.

Maybe, anyway.

 

To solve the problem of the vaginal microbiome, alongside the uterus transplant, a vagina and cervix from a ‘donor’ (read: a living, breathing woman) could also be installed into the transwoman.

 

This type of surgery from a living donor is, by Jones et al, admittedly dangerous. Indeed, women who have donated uteri already - not the other anatomical parts - have sustained massive injuries such as rectovaginal fistula (when the wall between the anus and vagina collapses).

 

Requiring multiple body parts from living women creates a dangerous market demand, as mentioned above. Women are already pressured and economically coerced into reproductive surgeries and procedures such as surrogacy. What kinds of outcomes would a demand for uteri and vaginas have on women living in poverty, women vulnerable to exploitation?

If you cannot see that the desire to ‘have a womb’, which involves the surgical removal of body parts from living women, is part of a colonial mindset where ownership and possession are valued over agency and freedom, then I suggest you reflect on what is being suggested here.  

One solution the authors offer to the issue of sourcing uterus-cervix-vaginas is to get these sets of body parts from willing transmen, as mentioned above. Of course these females would need to be up for the massive risk of a total hysterectomy-and-then-some. But then again, females donating their body parts would allow transwomen to ‘consolidate their female identity’.

 

There are already growing numbers of females who regret their gender transitions and surgeries.

How would these transmen, who constitute a vulnerable population, be protected from coercive medical institutions who seek to remove and sell their body parts?

 

So just to summarize, the solutions offered by Jones and colleagues to the challenges of installing uteri into male bodies involve:

• harvest organs from living, instead of dead, women

• harvest organs from transmen, who don’t want their uteri anyway

• harvest not only the uterus, but the cervix and vagina from transmen

• medically transition children, specifically boys, at younger ages

 

An evolutionary biological framework reminds us that sex and reproduction are not just simple parts and processes laid on top of a generic, gender-less human prototype. Every single cell has a sex, and sex chromosomes play key roles in regulating genetic expression throughout the entire body.

 

I believe these authors suffer from a major lack of insight into the complex interactions at play in gestation and birth. Much of the ‘female brain’ involves adaptations directly relevant to gestation and childrearing (for example, female-specific elaboration of the oxytocinergic system). The system has direct roles in preparing women for attentive, maternal behaviour (this does not mean that males cannot be sensitive parents, or that all women are attentive mothers). 

 

Indeed, maternal-fetal conflict has shaped the evolution of women’s immune systems and brain plasticity to be different than that of males, even if the women do not gestate themselves. Women, as the sex that conceives and bears offspring, have inherited a legacy of physical and psychological adaptations for pregnancy and birth, and at risk of sounding too biblical, these adaptations directly contribute to disease risk, pain and suffering.

 

Here are some additional ‘barriers’ not mentioned or considered by the authors:

1. Mismatch between sex of uterus and sex of body – it is known from a wide variety of organ transplant research that male and female organs function differently. When a recipient receives an organ from the opposite sex, it can have a higher risk of failure and rejection. This observation is not even mentioned in the target article.

2. Sex-specific priming of the fetal brain - In utero hormonal exposure permanently organizes the developing fetal brain in sex-specific ways. As described above, the brain initiates and responds to gonadal hormone secretion. How exogenous hormones given to maintain a pregnancy in a male body will impact hypothalamic feedback is unknown, but it presumably would not be the same as women, even if those males had received female hormones. Indeed, several studies demonstrate that exogenous hormones have opposite effects in male and female bodies.

3. Sex differences in fat and fetal nourishment - Females have evolved to have gynoid patterns of fat distribution, specifically fat on the hips, butt, and thighs. These fat stores are nutrient stores for the developing baby, especially their brains. Males do not have the same fat deposits, though sex hormones do increase their female-typical patterns of fat deposition. How the developing fetus would receive adequate nutrition in a male body must be explored (or not, just leave it alone please).

 

Overall, the argument is that having a uterus, especially one that is capable of menstruation and gestation, will make transwomen feel good. They will feel even more like women.

Validating the feelings of transwomen at the expense of women’s bodily integrity and safety, and the health of developing babies, is a shocking display of colonialism. This male quest for female body parts and experiences is misguided at best, and twisted and violent at worst.

Women are not repositories of body parts for the benefit of males, medical curiosity, and capitalism.

The functional integrity of women’s reproduction and the mother-baby dyad must be protected.

 

Leave our wombs alone.

 

 

 

Blog art by Minnette Vári

 

Main Reference 

1)    BP Jones, NJ Williams, S Saso, et al. 2018. Uterine transplantation in transgender women. International Journal of Obstetrics and Gynaecology, pg. 152-156.