Last month I did a speaking engagement for a classroom full of Georgia State University students, and at the beginning of my talk, I distributed index cards to the audience. I told them to write down any questions they’d prefer to ask anonymously, and I’d answer them during the Q and A period at the end.
One of the questions I got back was,
“Can a transwoman get pregnant?”
I gave what I thought at the time was a good answer: Nowadays, in an environment of greater information and acceptance, transgender people are transitioning sooner (i.e. before they’ve married and had children according to the more typical timetable of an American life). Therefore, it’s becoming more common for transwomen (and transmen) at the beginning of their transitions, before beginning surgeries or hormone replacement therapy, to make deposits of their gametes (sperm or ova or embryos) for later withdrawal, to preserve their ability to have children later in life.
This is a risky strategy, of course. The gametes may become nonviable by the time they’re needed. There could be an equipment error at the company holding them, for example, or a plain old bankruptcy or paperwork error or something like that. Furthermore, for these gametes to become babies, a womb with a willing owner may also have to be found. The prospective procreator may also have difficulty finding someone to supply the other set of 23 chromosomes. Other complications could also arise.
But these are risks many of us are willing to take, in exchange for transitioning and easing the suffering caused by gender dysphoria at an early enough age in our lives that we can express ourselves as our correct gender while we’re still young.
All of the above is what I said in response to the question. I still think it’s a good answer to the question I believed I was being asked. But, a few weeks later, I realized that I probably misunderstood. The questioner probably wanted to know whether the medical and surgical treatments available to help transgender women transition are thorough and complete enough, with regard to reproductive organs, that transwomen can afterward get pregnant and give birth.
In a word: no. Medical transitions can do amazing things for transgender women. Hormone replacement therapy (HRT) provides a body chemistry very similar to that of cisgender women. That same HRT causes breasts to develop
to some extent. It redistributes fat tissues to make our bodies more curvy and our faces more feminine. It softens our skin and lessens body hair.
Surgery can make further changes to our public appearance, and profound changes to our pubic appearance.
But there are no surgeries, medicines, or other therapies currently available that can provide functioning reproductive organs.
Gender confirmation surgery creates a vagina and labia, but this “birth canal” is essentially a blind alley. There’s no uterus behind it; no Fallopian tubes or ovaries. With the current state of modern medicine, there’s no way for female reproduction to ever be a part of the transwoman’s experience.
I didn’t grasp the real meaning of the question because I thought it was obvious that transwomen can’t have the organs necessary to conceive fetuses and gestate them to term. The questioner apparently thought we could.
This misunderstanding was probably my fault, because earlier in my talk, I told my audience that Lili Elbe, the famous “Danish Girl” of the recent movie, had received the transplant of a uterus and ovary. I also said that she had died as a result, but my audience may have assumed that improvements in treatment and techniques since then meant that today such transplants could now be done.
Well, they’re not routine, and currently not even really possible. I’ll go into some of the reasons why here, and then identify the reasons why it’s not likely that transgender women like me will be able to bear our own children anytime in the near future. I offer the usual caveat that I am not a doctor, so if you make medical decisions based on anything I’m about to tell you in this blog post, you’re dumb.
There are two methods for people to get new body parts. Well, three. One is pretty straightforward and is practiced every day. The other two are cutting edge and a little science fiction-y.
The first method is organ transplants. Organ transplants are major surgery, requiring surgeons with special training and equipment. A donor must be found. Tissue matches must be made. Often, the recipient must bank his or her own blood ahead of time for any transfusions needed during the transplant. After the transplant, there’s a risk that the transplant will be rejected. In some cases, this means the patient will have traded a poorly working organ for no organ at all.
The procedures became more conventional and less risky in recent years. Tissue matching is better; anti-rejection drugs are better, and there’s a thing doctors can do with bone marrow that often means there are no rejection issues at all.
Another development is that many more people are organ donors than used to be; in a growing number of states, licensed drivers are organ donors by default, instead of being required to opt in to the system. If you need a liver, or a heart, or sometimes lungs, your chances are better than they used to be that you can get one before your “original equipment” fails and you die.
But the thing about that, when talking about reproductive organs, is that you’ll die without a liver, or a heart, or lungs. Transplants are an option of last resort when there’s no doubt that the original organs have failed. There’s always some risk from major surgery like a transplant, and from the complications of having someone else’s body parts operating inside one’s body. Organ transplants are a thing only because the risk of the surgery is overshadowed by the certainty that some patients will die without the needed organs.
Such is not the case with reproductive organs. Transwomen will not die if we don’t have ovaries or uteruses. Transmen will not die if they don’t have testes. Transplanting organs not strictly necessary for continued living is an ethical gray area.
But medicine improves all the time, and some cisgender women are beginning to receive uterus transplants in experimental surgeries. At least one woman in Sweden has carried a baby to term and given birth with her mother’s uterus, transplanted into her own body.
There’s a logic to that. Not only did her mother no longer need her uterus; not only are they close enough relatives to make a successful transplant more likely; but by historical fact, the daughter received a uterus with a proven track record. She gave birth using the same uterus she herself began life inside. It’s like if M.C. Escher had been an obstetrician.
So, transwomen can just get transplanted uteruses from their own mothers and then give birth, right? Well, no. Hang on; it’s not quite that simple. For a transgender woman, doctors would have to make room for the uterus and find a way to attach it to nerves and a blood supply,
in an abdomen that wasn’t designed for it. And besides that, there’s still the matter of the embryo.
A cisgender woman without a functioning uterus may still have functioning ovaries. It’s routine, if expensive, to fertilize eggs in vitro and then implant them into a uterus to come to term; but a transgender woman doesn’t have her own ovaries or eggs. Maybe ovaries will also be transplanted one day along with uteruses, but that’s a more complicated surgery, and it would probably have a lower success rate.
And even so, another thing to consider is that an ovary begins its life with all the ova it will ever have. So even if a transwoman received a transplanted ovary and became pregnant with an ovum from it, the child that results from the pregnancy will biologically be someone else’s. If the point of the undertaking was for the transwoman to have her own biological children, then she still won’t have done that.
Of course, she might use ova from the transplanted ovary fertilized with some of her own banked sperm, but if the ovary came from a close relative, the embryo would, genetically, be a product of incest—a dicey proposition that could lead to birth defects, to say nothing of the social and legal taboos.
If the transwoman just wants to experience pregnancy, and it’s less important that the fetus has a genetic relationship to her, that may be possible with a uterine transplant, and good on her for that. But the birth itself would still have to be via Caesarean section. The cervix and vagina of a cisgender woman have complex muscular structures that would be absent from the vagina of a transwoman; a baby could not pass through it without ruining it, and anyway, the transgender mother would not be able to experience labor.
It would be no walk in the park for the fetus, either. The placenta wouldn’t have a natural place to attach, and the hormonal environment of the mother, even on HRT, might not be conducive to supporting the various stages of a pregnancy. There are many factors that wouldn’t even be knowable until the first time someone tried to cause a pregnancy in a transgender woman, and I think it would be unethical to use a potential human life as a lab experiment that way.
Artificially Grown Organs
Transplants are cutting-edge possibilities (no pun intended) today for transpeople who want to reproduce. Another possibility, currently only speculative, is that doctors could grow new organs for transgender women (and men) which could then be implanted.
This is a science that’s very much still in its infancy (again, no pun intended). Artificial bladders have been made for people. It’s very difficult to do even this, and the bladder is one of the simplest organs; it’s basically just a bag. More complicated organs like ovaries and Fallopian tubes will be several more years down the road. The same is also true for uteruses, which, again, are basically just bags.
Could female reproductive organs be grown from cells with an XY genome, or vice versa? I have no idea. So that would be an additional stumbling block.
And once all that’s worked out, many of the issues with transplanted uteruses would still remain. This possibility for pregnancy remains very far in the future.
Grown ovaries would allow our bodies to make their own estrogen and other female hormones. So there is that. I’d be up for that.
Neonatal care is getting so good that premature babies can survive after being delivered earlier and earlier before full term. The current record is 21 weeks.
At the same time, embryos can be implanted several days after fertilization, if necessary, although the longer the wait, the more likely the pregnancy to fail.
You can see where this is going: eventually babies will be able to skip a step, and go from fertilization to birth entirely in a lab somewhere, and never spend any time inside their mothers at all.
Obviously, if this is ever possible—in vitro gestation—anyone will be able to do it, not just transgender people.
While intriguing, I think all of these not-yet-available and “heroic” methods of bringing pregnancy to the transgender female realm are rather pointless, and potentially dangerous besides.
The desire to procreate is Darwinian.
I do understand the desire to procreate. It’s Darwinian, and Darwinian impulses tend to be the strongest. And in a world that often discriminates against an LGBT person’s right to adopt, having one’s own biological children is often the only avenue to becoming a parent.
That doesn’t mean we have to ourselves get pregnant, and the thinking that it’s somehow necessary to one’s womanhood to undergo a pregnancy is an essentialist fallacy, similar to transphobes’ claims that we have to have certain chromosomes or genitals to be considered “really” female. I reject it.
Many, many cisgender women, today, in the past, and in the future, have lived their whole lives without ever getting pregnant. It doesn’t in any way take away from their female-ness. If they have children via other means, means we ourselves could also take advantage of, they’re just as fit mothers, just as we would be.
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