- A New Delhi-based surgeon, Narendra Kaushik, has said that he will soon attempt a uterine transplant in a transgender woman in India.
- The transplantation of various organs is fairly well-understood – but in this case Kaushik is entering a scientific, social and ethical quagmire.
- Uterine transplants for transgender women appear to be out of the ambit of both Acts that regulate assisted reproductive technologies and one that regulates organ transplants.
- The privatisation of healthcare could also be responsible for a state of affairs in which vulnerable people are subjected to experimental procedures with no safety assurance.
- Uterine transplants will remain out of reach of most transgender women. Those who do access it will confront considerable risks as well as ethical and moral confusion.
In 1931, Lili Elbe, a Danish painter and a transgender woman, underwent the first uterine transplant in the history of medicine. But three months later, she died as a result of complications arising out of the surgery, which led to a cardiac arrest.
The transplantation of various organs is fairly well-understood – but in this case, experts told The Wire Science, Kaushik is entering an ethically murky territory that is also a scientific and social quagmire.
Kaushik’s claim comes exactly half a decade after Shailesh Puntambekar, an oncosurgeon, successfully transplanted a uterus into a cisgender woman. Before the procedure, she had had a syndrome in which excessive scar tissue on the walls of her uterus had resulted in an inability to conceive. She underwent the procedure in May 2017 and gave birth to a child around one and a half years later through in vitro fertilisation (IVF).
Surrogacy and uterine transplants remain the only ways for someone with uterine factor infertility – medical conditions where the uterus is either absent or unhealthy – to biologically reproduce. However, physicians around the world haven’t found much success with transplants. According to a 2018 paper, the first four attempts in the US were rendered unsuccessful by post-surgical complications.
The same paper also wrote that uterine transplants “should be considered a clinical experimental procedure until a sufficient amount of experience has been collected from clinical trials”.
To date, there have been no reports of any transgender woman other than Elbe, the Danish painter, having undergone a uterine transplant. Further, the Montreal Criteria for Ethical Feasibility of Uterine Transplantation of 2012 considers only persons assigned female at birth (i.e. “genetic females”) to be able to receive a transplanted uterus.
Conversations around uterine transplants for transgender women in particular began only recently. A 2021 paper from the UK reported that around 94% of transgender women the researchers surveyed (total: 182) expressed a “desire to have children in the future”; and 94% and 88% of respondents agreed respectively that “the ability to gestate and give birth to children, and [to] menstruate would enhance perceptions of their femininity”.
The survey also found that 99% of the respondents believed uterine transplants “would lead to greater happiness in transgender women”.
But the study was limited by some problems – including, it admitted, the fact that the researchers who conducted it didn’t describe the risks of uterine transplant in detail.
The paper also warned that participants were self-selected, opening the results up to self-selection bias and rendering them, according to the paper, “not extrapolable to all transgender women”.
Who wants to be mothers?
According to a News18 report, Kaushik has expressed the belief that “every transgender woman wants to be as female as possible,” including in their ability to conceive children. Zee1, a New Delhi-based doctor who also identifies as a transgender woman, told The Wire Science that Kaushik’s claim is not true: “Not all trans women want to medically or surgically transition.”
Transgender identities in general and transfeminine identities2 in particular are very diverse. For example, anthropologist Don Kulik has written about Travestis – transgender persons in Brazil who sign up for cheap, and sometimes harmful, feminisation procedures but prefer to not undergo orchiectomy (removal of testes) and penisectomy (removal of penis). According to Kulik, Travestis never wish to be a replica of cisgender women. Instead, they say that they are “like a woman”.
Another example is that of the Shivashakti, a religious and cultural transfeminine community in Telangana and its bordering states. Its members often deck up in heavy ornaments and conventionally feminine clothing. At the same time, Shivashaktis often marry cisgender women and conceive children out of these relationships.
Travestis and the Shivashakti are just two of several social and cultural transfeminine identities, which also encompass the Hijra and the Kothi among others – none of whom align with the conventional understanding of femininity and womanhood.
The News18 report also quoted Kaushik as saying procedures like uterine transplants help transgender persons reach the “aesthetic ideal” of femininity since they make “the patient’s life as normal as possible”. But according to Zee, the very idea of an “aesthetic ideal” is problematic.
She recalled that during her early discussions with her plastic surgeon, he had also advised that she get several auxiliary surgeries beyond the routine transfeminising surgeries to “feminise [her] forehead, jaws, upper lip, chin, Adam’s apple, nose and eyebrows.” She added, “I didn’t have dysphoria specifically related to my face, but at that time, in his clinic, I was made to feel that my face is very masculine. This dysphoria was created by my own plastic surgeon.”
Gender dysphoria is the discomfort or distress transgender persons report feeling due to the mismatch between their experience of their gender and society’s expectations of their sex assigned at birth.
Zee said that the “aesthetic ideal” of femininity conflates carrying a pregnancy (gestation) with womanhood, and oppresses transgender as well as cisgender women.
Zee pointed out that cisgender women don’t cease to be women if they undergo a hysterectomy (surgical removal of the uterus) or a mastectomy (surgical removal of the breasts). In the same vein, she added, it doesn’t make sense to hold transgender women to such unfair biological standards of womanhood.
“It’s absolutely artificially created dysphoria.”
Guidelines, laws and bioethics
The World Professional Association for Transgender Health (WPATH) Standard of Care (SOC) guidelines of 2012 – accepted worldwide vis-à-vis the care of transgender and gender non-conforming people – recommends four interventions to alleviate gender dysphoria.
- Affirming changes in gender expression and role consistent with one’s gender identity;
- Hormone therapy for feminising or masculinising one’s body;
- Surgical intervention to “change primary and/or secondary sex; characteristics,” including “breasts/chests, external or internal genitalia, facial features and body contouring”; and
- Psychotherapy for “addressing the negative impact of gender dysphoria” among other reasons.
Zee said that surgical interventions are usually kept to a minimum since surgeries are in general inherently risky. So surgical intervention is recommended only to the extent that it helps transgender women deal with dysphoria and allows them a “good sexual life”, together with endocrinological and psychotherapeutic support.
Other than that, she added, the WPATH SOC guidelines don’t even consider “procedures like ovarian or uterine transplantation”.
Kiran Naik, a plastic surgeon practising in Mumbai, and Richie Gupta, a Delhi-based plastic and reconstructive surgeon, echoed Zee. Both Naik and Gupta have performed gender-affirming surgeries. “In my opinion, a uterine transplant right now is very complex,” Naik told The Wire Science. “I discourage it as a procedure currently because it carries significant morbidity and involves many long-term risks.”
Rohin Bhatt, a queer lawyer and who recently graduated in bioethics from the Harvard Medical School, went a step ahead and called Kaushik’s forthcoming transplant surgery a “bioethics disaster”.
According to him, there is a blind spot with respect to regulating uterine transplants even among cisgender women, and as a result Kaushik’s experimental procedure lacks ethical oversight.
“Are we going to regulate this as organ donation?” Bhatt asked. “Or are we going to regulate this as [a form of] assisted reproductive technology?”
The answer matters because these two procedures are governed by different laws in India. Organ transplants fall under the Transplantation of Human Organs and Tissues Act 1994, which allows transplants only for “therapeutic purposes”. Such purposes include replacing a critical organ, like the liver or the kidneys, if they fail to function properly – or when such an organ has to be removed due to a medical condition like cancer.
According to Sanjay Nagral, a transplantation surgeon who also works with the Forum for Medical Ethics, medical practitioners have historically encouraged organ transplants only when they were deemed to be life-saving. But he also told The Wire Science that physicians have of late been transplanting organs also – such as hands3 – when they can significantly improve the recipient’s quality of life.
For a procedure to be treated as an ‘organ transplant’, it must have a therapeutic purpose. According to Bhatt, uterine transplants may not make the cut.
Two Acts govern the use of assisted reproductive technologies (ARTs) in India: the Assisted Reproductive Technology (Regulation) Act 2021 and the Surrogacy (Regulation) Act 2021. According to Bhatt, if Kaushik’s planned procedure is to be regulated as a form of assisted reproductive technology, the next question asks itself: will it be considered to be a form of an IVF procedure or as gestational surrogacy?
(These are the two most common types of ART in India.)
The 2021 ART (Regulation) Act defines ARTs as “all techniques that attempt to obtain a pregnancy by handling the sperm or the oocyte outside the human body and transferring the gamete or the embryo into the reproductive system of a woman.” Bhatt added that the Act only refers to cisgender women, not transgender women.
So uterine transplants for transgender women appear to be out of the ambit of both the Acts, rendering it an essentially unregulated procedure at the moment.
“[Indian] law has not yet foreseen a transgender woman being a gestational mother,” Bhatt said. “It always seems to be playing catch up with science.”
Risk, uncertainty and doubt
Nagral wasn’t sure if uterine transplants could be considered to be “life-saving”. They could however serve a therapeutic purpose, Zee said, for transgender women who desire to be gestational mothers.
But she also said that the risks resulting from the complex nature of the surgery and the medical suppression of the recipient’s immune system (so that their body doesn’t reject the transplanted organ) may not justify the benefits.
A uterine transplant usually has four major steps in the following order:
- A viable uterus is retrieved from the donor along with part of the cervix – the passage that connects the vagina and the uterus.
- This uterus is transplanted into the recipient. Once the uterus is placed in the body of the recipient, surgeons connect it to the recipient’s blood vessels, muscles and cartilage. But the fallopian tubes – the passageways that carry eggs from ovaries to the uterus – can’t be connected. So the recipient can only conceive through IVF.
- Once the pregnancy is close to term, surgeons perform a caesarean section to deliver the baby. This is because women with uterine factor infertility – the group that is traditionally the target for uterine transplants – are unable to deliver via the vagina.
- After childbirth, the transplanted uterus is removed from the body of the recipient, allowing the recipient to be weaned off immunosuppressive drugs.
Each of these steps is a major surgical event on its own, so there are significant risks to the lives of both the donor and the recipient – as with any transplant. Immunosuppression adds to these risks by increasing the recipient’s vulnerability to many infections.
Bhatt said the problems don’t stop there. After childbirth, the transplanted uterus is removed from the recipient and the recipient is weaned off immunosuppression. “If they refuse to have a hysterectomy, what do we do then? You can’t tie somebody to a bed and force them to have a hysterectomy.”
According to principles enshrined in Indian law, no medical procedure can be conducted on a person unless they have provided informed consent in a form valid in law (barring “specific cases of emergency”).
But consent isn’t so simple in India, as both Nagral and Bhatt also pointed out, especially among marginalised and vulnerable populations. Bhatt mentioned how women are often coerced by their family members to bear children, consent be damned. “Forget about uterine transplants,” Nagral added, “even routine infertility treatments are often taken up by women due to societal pressures.”
On an adjacent front, a lack of regulatory guidelines could leave cisgender women vulnerable. This is one of the constituencies expected to donate uteruses if uterine transplants become more desirable.
“What if cisgender women’s families or in-laws force them to donate their uteri for money or other gains?” Bhatt asked. “Although the law explicitly prohibits non-altruistic [organ] donations of all kinds, we would be kidding ourselves to say that that does not happen.”
Indeed, many of these issues persist even in the case of cisgender women – which highlights both the doubly fraught nature of what Kaushik has proposed to undertake and the lack of consensus on whether the procedure is warranted or desirable.
Soumya Swaminathan, former head of the Indian Council of Medical Research, said in 2017 that the country doesn’t “have a committee to look into this specific form of transplants” – referring to transplants of the uterus.
For Nagral, it is important to understand whether uterine transplants are experimental or therapeutic.
“If it is experimentation,” he asked, “has it gone through the steps required for an experiment involving human participants?” He also wondered if the recipient had been told that they may “potentially die or have major side effects” as a result of the procedure.
Kaushik did not respond to The Wire Science’s request for an interview. This article will be updated as and when he does.
Privatisation leads to exclusion
Kaushik’s claim comes at a time when transgender persons in India are struggling to find their space in the public health system – despite the Transgender Persons (Protection of Rights) Act 2019 directing the Union and state governments “to provide … medical care facility including sex reassignment surgery and hormonal therapy.”
Nagral said the profit-driven privatisation of healthcare could also be responsible for the current state of affairs, in which vulnerable people are being subjected to highly experimental procedures with no safety assurance.
For example, more than 75% of organ transplants in India reportedly happen in private hospitals. Cosmetic and plastic surgery “is now a big area of expansion for the private sector,” Nagral told The Wire Science.
Many transgender women also resort to sex work and begging for their income and remain economically and socially marginalised. They are thus unable to access routine medical and surgical transition procedures. Zee said that the latter (excluding endocrinological and psychotherapeutic interventions) can cost around Rs 4-5 lakh.
Hindustan Times estimated in 2017 that a uterine transplant can cost Rs 7-8 lakh.
Taken together, uterine transplants will remain out of reach of a majority of transgender women – and those who will be access it will confront considerable risks as well as ethical and moral confusion.
As Zee put it, “Who is this surgery for?”
Sayantan Datta (they/them) are a queer-trans science writer, communicator and journalist. They currently work with the feminist multimedia science collective TheLifeofScience.com, and tweet at @queersprings. Pushpesh Kumar is a professor of sociology at the University of Hyderabad.