A young British transwoman: "I just want to have a baby"
|
8 January 2025: I've discovered that there are many external links this page - which had some badly out of date content. To avoid and minimise potential issues I have thus made some deletions and a few updates. But I must emphasise that no medical advice or recommendations are being given, and I can't accept any liability for any decisions made based on its content. Nomenclature: There is currently (2020) intense pressure from LGBTI+ activists to avoid the use of words such as 'man' and 'woman' in a sexual and reproductive context. This campaign has had great success, for example the Australia National University’s Gender Institute Handbook suggests that the word 'mother' be replaced by 'gestational parent', and 'father' by 'non-birthing parent'. In the UK, the hugely influential charity Stonewall is requiring organisations (including schools and children's hospitals) to replace the words "boy" and "girl" with gender neutral terms such as "they". However, the first version of this article was written in 2001 using traditional nomenclature - which I'm very reluctant to change.
By 2000 two potentially viable medical procedures were identified to help cis-women without a functional uterus who were seeking to bear a baby (an estimated 1 in 500 women) - an ectopic pregnancy and a uterus transplant. The procedures were also relevant to the rapidly increasing number of transwomen. Both procedures are discussed below, but only the later has so far emerged as practical.
The Female Reproductive System Before going any
further it is necessary to consider the primary sexual organs needed to
become "pregnant".
Additionally, women have a unique secondary sexual characteristic that for a million years was critical to the survival of a baby after birth - their breasts can lactate milk. The Reproductive System of TranswomenWhen high-quality gender confirmation and other feminisation surgery using modern techniques is combined with hormone treatment, the resulting external appearance - including the vulva - of many young XY male-to-female (MTF) transwomen is indistinguishable from that of a cis-woman at their peak fertile of age 20-30. However, their neo-vagina does not lead on to a cervix. Indeed, the cervix, uterus, ovaries, fimbria and fallopian tubes are all missing. The reality is that a transwoman lacks the internal organs required to become pregnant.
The internal anatomy of a XX woman (left) compared with a XY
transwoman after gender confirmation surgery.
Theoretically a dramatic hormonal and micro-surgery intervention on
an embryo with male XY genes might result in the development of a
baby with internal female sexual organs, but there is no obvious and
ethical reason for doing this.
Before 2000 an ectopic pregnancy - the development of
the baby outside the uterus (womb) - seemed the most likely procedure
for transgender women as it was medically simple because no transplants
were required. The technique involves attaching the foetus (the term used
for developing babies under 8 weeks from conception) to the muscles inside
the woman's abdomen, or an artificial womb formed from abdominal tissue.
Attachment to the bowel, with its good blood supply, is another attractive
option, but perhaps the worst in terms of post-delivery trauma.
Unfortunately there are two big problems with the ectopic
procedure: Natural occurrences of ectopic pregnancy do a occur,
however they are considered very dangerous to the mother. By 2010 interest in this procedure had faded because of
the risks that it involves for the patient, and the advances being made
with uterus transplants.
Uterus Transplant The possibility of uterus transplants dates back to the origins sex-change surgery in the early 1930's. Lili Elbe (born Einar Wegener) famously had the one of the earliest documented uterus implant operations in June 1931. She sadly died just three months later from the complications. After early failures, uterus implants were not regarded as a viable approach. Experiments with dogs and baboons in the 1980's were unsuccessful as it was found to be very difficult to connect the required numerous blood vessels. Pregnancy also puts huge strain on these connections, with very dangerous consequences if something goes wrong.
However, in the 1990's the concept of a short-term (one to two years) uterus implant purely to bear a baby emerged. Patients would still need to take immunosuppressant drugs to help stop their body immediately rejecting the uterus but researchers believed that the latest immunosuppressant drugs did not have any negative effects on a foetus. After the woman had her child, the transplanted womb could be removed, avoiding long-term risks such as rejection and undesirable side effects from the drugs. This idea started what effectively became a competition for the first successful pregnancy via a uterus transplant.
In order to reduce the high risks, it was desirable that the uterus came
from a woman with a close genetic match to the recipient in order to
minimise the chance of rejection, as the womb does not deteriorate greatly
from age it could come from a post-menopausal woman. According to Dr
Brännström "It could well be a relative. You could get it from your
mother. You could give birth to a baby from the uterus that you
yourself were birth from."
In January 2014, Dr Mats
Brannstrom revealed that the Gothenburg team had conducted nine womb
transplants on women who were born without a uterus or had it removed
because of cervical cancer. On 5 October 2014, one of these women -
Malin Stenberg - become the first in the world to have a baby after having
a womb transplant. The 36-year woman was born without a uterus,
received a donated womb from a "post-menopause 60-year old friend" in a
very long operation - it took a little over 10 hours to remove the uterus
from the donor, and just under five hours to stitch it into the recipient.
The woman must take immunosuppressive medications to prevent the body from rejecting the transplanted uterus. After the baby is born and if the woman does not want more children, the transplanted uterus is removed with a hysterectomy procedure, and the woman no longer needs to take anti-rejection medications.
For a transsexual woman absolutely determined to start a family, a uterine transplant offers major advantages over surrogacy. The transwoman is gestationally and socially clearly the mother. She can also control lifestyle factors such as smoking and drinking alcohol, and she is the person who takes the health risks associated with every pregnancy. But crucially, if the foetus is created using her frozen sperm, then she is genetically as close the baby as any cis-woman is of her baby.
However not all doctors are quite so positive. Dr J. Richard Smith of Imperial College London, who co-led the first uterus transplant performed in the UK believes that “the transgender community have been given … false hope for responsible transplantation in the near future". He explained that even cisgender women who need surgery to create a neovagina aren’t eligible for the uterus transplants his team are offering as part of a clinical study. They have an altered vaginal microbiome that appears to increase the risk of miscarriage.
Ethical and Other Considerations An unusual aspect about uterus transplants is that currently they’re meant to be temporary. Typically a woman receives a uterus via transplantation, its implanted with an embryo created via in vitro fertilisation (IVF), she gives birth via caesarean section, and then has a hysterectomy to remove the uterus. This is very different from other more routine organ transplants like heart or liver transplants, which are intended to be permanent once they’re put into the recipient. A uterus transplant is also not a lifesaving procedure in the same way a heart transplant would be.There are also questions concerning donation and the assignment of organs - for example, what if a donor specifies that they only want to donate their uterus to a cis-woman, and not to a transgender woman? There is then an overlap with legal consideration as withholding a uterus to a transgender woman could breach anti-discrimination laws. In the UK the Human Fertilisation and Embryology Act 2008, states that an embryo has to be implanted into a "woman", it would thus be illegal for an IVF clinic in the UK to create an embryo for the purpose of implanting it in a transwoman with a uterus transplant in order to make her pregnant. However the later Equality Act 2010 superseds this by clarifying that for legal purposes a transwoman is a woman, as long as they've gone through the legal process of being recognised as a woman. It would thus be illegal to refuse to a uterus transplant to a transgender woman solely because of they are transgender. Chloe Romanis, an Associate Professor in Biolaw at Durham University, Laura O’Donovan, a research associate at Lancaster University and Dr Hammond-Browning at Cardiff Law School, make several important points regarding transwomen having uterus implants which I have tried to aggregate these:
Dr Brännström believes that it might be possible to transplant a womb into transsexual women, allowing them to become pregnant with using donated eggs, though anatomical barriers would have to be overcome. "It should be technically possible, but I don't know if it's ethical." The crucial caveat is a reference to the Montreal Criteria for the Ethical Feasibility of Uterine Transplantation. It's an ethical framework published in 2012 designed to assess whether a woman could be considered as a transplant candidate. Among the list of qualifying criteria is the requirement that the uterus recipient should be a "genetic female of reproductive age". Whilst surgeons and medical teams are reluctant to risk not complying with a widely accepted ethical standard, the Montreal Criteria has become controversial as it prevents transwomen having a uterus transplant. There has thus become a campaign, led by Dr. Jacques Balayla from the McGill University, to remove the reference "genetic female" from the Montreal Criteria. He states in an interview dated March 2021 that: However, there seems to be no likelihood that the criteria will be amended in the near future, so any surgeon or hospital conducting a uterus transplant on a transwoman will be on a risky solo run. Detailed Procedure Assuming that the mother and her medical team have determined that the risks are acceptable, the key steps for a transwoman to become pregnant are:
The diagram above shows the result of a theoretical uterus transplant procedure for a trans-woman. The transplant includes the cuff of the donors vagina, which is shown connected to a neo-vaginal canal probably constructed from penile skin and tissue - this is very useful for access to the uterus and clearing hormone induced menstrual flows. Obviously there are no ovaries and the uterine tubes have been truncated. After surgery there would be a c.12 week recovery period and the patient would require immunosuppressant drugs so that her body wouldn’t reject the new organ. The patient may need to wait a year before doctors will risk transplanting embryos into the new uterus, carefully prepared with hormones. If all goes well, the patient will become pregnant and carry her baby to term, for birth by C-section.
These images of Argentinean television celebrity Florencia de la Vega (Flor) provide a look into the near future. She was born Roberto Carlos Trinidad in 1995 and transitioned age 16. She thereafter worked as a showgirl and TV actress, and probably had SRS in 2010. In early 2011 she married Pablo Goycochea, age 36. Soon after, in August 2011, they announced the birth of twin babies - a boy and a girl. The front cover of Gente magazine shows Flor with the newborn twins whilst inside there was a carefully posed picture with her belly emphasised, which could easily be mistaken for showing her pregnant. Whilst the supporting article repeatedly referred to Flora as the twins mother, it never explicitly states that she had been pregnant and given birth to them. In fact the twins are the result of her husband's sperm impregnating a surrogate mother. The magazine continues to regularly feature Flor and her children.
A transwoman lacks the ovaries needed to produce an ovum containing her genes, and more specifically 23 of her chromosones. Thus, until the 2000's the primary method for a transwoman to gain a baby was having the egg of a surrogate mother being fertilised by sperm from her husband or partner, and the resulting baby being adopted after its birth. Clearly this approach is somewhat unsatisfactory for the transsexual woman as she has no genetic relationship with her baby.
Also, for many years there has been speculation about potential new options which use a cloning technique called "membrane fusion" to create a fertilisable egg. A surprisingly simple technique has now emerged. Basically, a woman donates an ovum egg. The nucleus, containing this woman's DNA, is removed, and a nucleus with genes (including two paired sets of chromosomes - totally 26) extracted from one of the transwoman's skin cells is put into its place. The ovum realises that it has too many chromosomes and discards half of them, thus creating an unfertilised egg with just one set of 13 chromosomes. Using standard IVF techniques the new ovum can then be fertilised by the father's sperm and implanted into the uterus of a surrogate mother. Both the mother and her husband/partner will have a a normal 50% share of the baby's gene's.
When the first version of this page was drafted in 2001, the idea of a genetically XY male-to-female transsexual becoming pregnant was still close to science fiction. Over 20 years later it's clear that all the major medical barriers have now been overcome. Indeed, it is quite possible that somewhere in the world (most probably in Brazil) a transwoman has already quietly given birth.
TThe next problem is cost. Uterus transplants are only just moving from research to mainstream, and as such are still being hugely subsidised. Although uterus transplants are starting to become an accepted medical procedure, few public health services or health insurance policies are likely to cover them due to the very high cost, indeed health insurance policies are starting to specifically exclude it. The UK's NHS estimated in 2020 that prospective "routine" uterus transplants procedures involving a cis-woman would cost about £50,000, however this was just for the two operations (donor and recipient) plus immediate pre- and post-operative care. Other estimates are even higher, in 2019 the American based UTX group estimated $200,000 for a uterus transplant, whilst an article in PubMed estimated €50,000 to €100,000 (mean €74,000) in Year 2020 values per uterus transplantation. The total medical costs over 3+ years for a transgender woman to go through all stages from gender confirmation surgery, uterus transplant, pregnancy, birth and finally uterus removal could easily be £/€/$ 1 million. And that is just the direct medical expenses, without even including other factors such as loss of earnings. Pregnancy and motherhood seems likely for many years to be a privilege reserved for transwomen with substantial personal wealth or a rich husband.
Part 2 of "Transsexual Pregnancy"
(c) 2000 - 2024 Annie Richards Please send any comments, feedback or additions to: Last updated: 17 February, 2023
| |
The stress of being infertile, unable to get pregnant, not able to have
babies negatively affects the mental health of tens, if not hundreds, of
thousands of transwomen around the world. For example, a 26-year-old
transwoman in the USA with two adopted children was reported by the
New York Times
as: "craving to become pregnant ... I want the morning sickness, the
backaches, the feet swelling. I want to feel the baby move. That is
something I’ve wanted for as long as I can remember."
The
internal reproductive organs of a genetically XX woman include:
A
Researchers
then sought better ways of "plumbing in" the transplanted uterus than the
Saudi's had used. In
June 2003 a Swedish team led by Dr Brännström of Sahlgrenska University
in Gothenburg, announced a new technique where the transplanted womb is
attached to two arteries and three veins on each side, with blood
primarily coming from the external iliac artery. It would also be
attached to the vagina, and to the round and sacral ligaments to hold it
in place, but not to the Fallopian tubes - if the woman has those.
The woman would not be able to conceive naturally, but would have to have
IVF. She would also have to give birth by Caesarean. The
technique was considered simpler and less risky than most transplant
operations
Back to Articles