WHY WE SHOULD BE WORRIED ABOUT THE PROPOSED UTERINE TRANSPLANTATION FOR TRANSGENDER PERSONS?
Dr Narendra Kaushik created a buzz in the Indian media recently when he announced to the world when he announced that he plans to perform a uterine transplant (UTx) on a transgender woman allowing her to get pregnant. This might seem prima facie seem like a welcome step in ensuring reproductive equality between cis and trans individuals, but it becomes more complex when to date, only one trans person has been a patient in such a surgery and she died of complications from the surgery. The first modern attempt had to result in removal 99 days after implantation due to complications. What does it mean to take a vulnerable population, and subject them to experimental procedures? This opens up a pandora’s box of bioethical and regulatory issues which I will grapple with in the article which could complicate the aftermaths of this surgery.
But first, the basics- how does the procedure work? The answer to that is quite simple, according to the University of Pennsylvania Medicine’s Uterine Transplant Programme — like any other organ transplant, the doctor would remove a uterus from a dead donor and transplant it into a living person, in this case, a transgender woman. After that has happened, a fertilised egg would be transplanted into the transplanted uterus, just like an IVF procedure. The uterine recipient would then be a gestational parent for the course of the pregnancy. After the gestational period is over, the baby would be delivered via a caesarean section, and the uterus would then be subsequently removed.
A plain reading of the procedures would indicate that there are two steps involved in the procedure- an organ donation and an IVF, both of which form a part of UTx. The question is how should UTx be governed? Notably, organ donations are governed by the Transplantation of The Human Organs Act, 1994 which only allows for organ donation for therapeutic purposes. Whether UTx is a therapeutic procedure is a debatable question. The second issue is if it were to be considered an Artificial Reproductive Technology laws, i.e. the ART Act and the Surrogacy Act, then the issues will you consider the patient as a single gestational surrogate or as a single woman getting IVF? Only the latter is allowed under the Indian law as it now stands. This procedure combines the hitherto unknown collaboration between two medical procedures which are usually governed differently in most jurisdictions, including US and UK.
Unlike other organs, uterus restitution is theoretically possible, as a more probable prospect for kidney and heart transplant, does this bring on a new era of ‘renting the womb’, a term previously used for surrogacy. What happens if a woman who chooses to have such a transplant refuses to consent to a hysterectomy? Under Indian law, patient autonomy is sacrosanct; that is, no patient can be subjected to a procedure that they do not consent for.
The procedure is arguably a regulatory nightmare, but more importantly, it raises a plethora of ethical questions that I will grapple with in the next part of the article.
UTx calls upon us to fundamentally examine the social value of gestation. Such a procedure will serve to reinforce the motherhood mandate. In the interview that gained attention, Kaushik proclaimed that being female meant that a woman should be able to reproduce and conceive. With the advances in science, there is undoubtedly an increased reproductive autonomy. But at the same time, it reinforces cultural and social norms about the ideas of womanhood and intensifies the desire to procreate using ARTs and the harm when the same cannot be afforded. According to a survey by Sangma which interviewed 3,619 transgender persons, it was found that 12% of the transgender persons were employed and half of the respondents made less than Rs 5,000 per month. It is evident that transgender persons are extremely vulnerable and such experimental procedures are extremely expensive. The buzz around this procedure creates cruelty of hope for transgender persons when there is little known success around this procedure.
But the issue is not only limited to transgender women. Cis women, who are unable to get pregnant, will undoubtedly be forced into such procedures to get pregnant. According to a study carried out in Uttar Pradesh, reproductive coercion from the husband and in-laws remains a major barrier to reproductive freedom in India. It demonstrated that 1 in 8 women suffer poorer outcomes including unintended pregnancies. This procedure will potentially play a major role in forcing thousands of women into gestation and motherhood and have a chilling effect on reproductive autonomy. It will also have significant detrimental effects on the mental health of the patient in case the procedure fails.
A right to reproduce is read into Indian law as a necessary part of the right to life which is enshrined in Article 21of the Constitution. However, UTx is an experimental procedure. What is proposed is bioethically dangerous, because it takes a vulnerable population who is often rejected from their biological families and gives them hope of creating a biological offspring. The widespread media coverage that this proposed procedure has had in Indian and international media is perhaps a pie in the sky, unlikely to achieve success in the near future. This procedure raises major ethical and regulatory questions, some of which I have highlighted in this article. What are the ethical limits of medicine? Should limited resources of funding be diverted to such experimental procedures? How can we tackle the harms of infertility while ensuring the proper protection of a vulnerable group? And the most important, what is the value of gestation in womanhood? This procedure raises more murky questions than it answers. One remains optimistic about these procedures, but unless the data on the feasibility and the safety of such procedures are established, they should be avoided to be carried out. More so in a vulnerable population. What happens in the future remains to be seen, but one hopes that this will point the regulators and legislators to urgently debate and form legal, ethical and regulatory guidelines around uterine transplant before it is too late.