The AMA Examines the Idea of Subsidies for Uterus Transplants for Trans People

(Cleveland Clinic Center via AP)

One of the problems with a buckshot-style news cycle is that things can slip past the public and become old news very quickly. And, in some cases, we are talking about news items that are indicators of fairly serious trends. Take, for example, a June article in the AMA Journal of Ethics® that floats the idea of using taxpayer funds for uterus transplants (UTx) for transgendered people. The article begins by discussing who might benefit (along with actual women) from such a procedure.

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Among those likely to be interested in UTx are transwomen who want to gestate their own children, transwomen who want uterus transplants to consolidate their identities but not to gestate children, some transmen who want to gestate their own children, and cismen wanting to gestate children of their own. Transwomen and cisgender men will not have been born with a uterus, and transmen might have had female-typical bodies in the past but lacked a uterus for reasons of disease or disorder. Here, we understand transgender people to be those who meet American Psychiatric Association or World Health Organization standards for gender dysphoria or gender incongruence respectively.

It is worth noting that uterus transplants have been successful in real women. That is because one may assume that real women have the rest of the corresponding biology necessary to accommodate one. But if I read this correctly, this treatment could, among other things, give natural, heterosexual men the ability to carry a child. Medical science has not reached that point. Be that as it may, forgive the presumption that this would seem to indicate that we are approaching a point at which the natural-born woman is becoming obsolete. Forget about the drag queen events, the now-exhausted Bud Light and Target debacles, or even the ad campaigns using “womanface,” such as the latest offering from Mrs. Meyer’s Clean Day. What we have here are medical professionals debating subsidizing a process that could make women completely non-essential. Also, note the idea that having a uterus will make a man feel more complete as a woman by “consolidating” his identity. We seem to be quickly approaching Mary Shelley territory. And we need not ask where the feminists, the pro-choicers, and the people in Handmaid’s Tale garb are. We know where they are. They are following the madness right off the cliff.  They will, of course, go happily to their own demise. It truly is becoming a man’s world, no matter what a man may call himself. Granted, the article is only a discussion of the procedure, but why even discuss it in the first place? Perhaps the AMA knows that such things will become mandates in the near future. It remains to be seen what the AMA’s reaction will be when that threshold is finally crossed.

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Related: Medical School Professor Says Trans Kids Can Identify as ‘Gender Hybrids’ Like ‘Minotaurs’

Of course, such surgeries are not cheap. The article states:

In the United States, the costs of UTx have been estimated to run between $100,000 and $300, 000, and these costs are typically paid by institutions themselves or through research grants supporting clinical trials. A few institutions offer UTx to cisgender women paying out of pocket, although these women’s insurance might cover some of their expenses that would ordinarily be paid by health insurers for pregnancy and childbearing.

No reliable estimates exist on how many transwomen, transmen, or cismen might be candidates for or want UTx, and even a rough estimate of what the individual cost might be for such people can only be speculative, especially since no UTx has been reported in such parties. However, the overall total financial cost of UTx for these parties would likely be smaller than the overall total cost for cisgender women because of the comparatively smaller number of transpeople and the even smaller subset likely to be interested in this intervention. In this analysis, we consider the comparative moral strength of transwomen’s and transmen’s claims for financial support.

The article does take the time to discuss the pros and cons of subsidizing UTx. It mentions that UTx could restore a woman’s ability to become pregnant and might provide “access to a good that is fundamental to social status equality.” It suggests that an argument can be made that someone could be eligible for a UTx subsidy along the lines of other transplant subsidies. It also suggests that the case could be made that:

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…coverage for UTx is contractually implied in private insurance policies to the extent that these policies provide fertility coverage—as happens, for example, in states that require health insurers doing business in their state to provide a certain degree of subsidy for IVF.10 In general, IVF and other interventions in fertility medicine are not subsidized by government or private insurers in the United States.

In terms of “transwomen who want to gestate children,” the writers note that there are no medical barriers to such a procedure. Since “transwomen” cannot bear children, they risk what the writers call “psychological dissonance in a way that undermines their health and well-being.” It is also argued that in this state, these people experience an obstacle in fully participating in things that are a part of a woman’s identity. The article also cites an argument that while no woman with a UTx has been able to become pregnant, the government should support research toward that end in the name of equity. In terms of adoption, the idea is presented that transwomen may claim that adopting a child is no replacement for gestation and that there are obstacles faced by minorities and transgender people in the adoption process.

When it comes to “transwomen who want to consolidate identity, ” the authors note that some of the above criteria may apply. but the main issue seems to be that such people may experience dissonance over not having a uterus.  But the authors do note:

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In contrast, UTx offers no comparable outward benefit, which is not to say that it is of no value, only that it might be evaluated as less important than other health care interests, especially if the risks of the intervention are not offset by a sufficiently important gain. It is also an open question whether carrying out UTx for one person’s identity consolidation would close off the option for another person to secure UTx in order to have a child, in which case questions of justice would necessarily be involved, involving competing claims on limited resources. Moreover, UTx as currently practiced involves only temporary placement, whereas a uterus might be wanted indefinitely, thus exposing the individual to much longer-term risks of immunosuppression. Third-party payers might, again, reasonably judge a transient medical intervention less important and riskier than others, especially since for private insurers and governments alike resources will be limited.

In this case, we are talking about a biological man who does not have a uterus but wants to take one from another potential recipient who is a natural woman. Unless we do reach the point in which such uteruses can be made fully functional, this amounts to a biological man having an organ transplanted into his body using the rationale that he wants one.

Finally, the article talks about “transmen who want to gestate children after gender-affirming surgery.” Keep in mind, in this case, this would be women who were presumably born with a uterus to begin with and underwent the surgery. The article states that:

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…transmen cannot claim that they lack a capacity characteristic of men that compromises their health or that compromises status equality with other men. Unless one wants to argue that all people have a fundamental interest in gestating, it is not clear that men lack a capacity they ought to expect as a matter of reproductive justice.

The article also points out that “transmen” have the same options for having children as any other adult facing infertility. The authors note that there might have been a failure by a clinician or a facility to talk with the patient about keeping her uterus for future use, which could theoretically result in a call for restorative justice. However, they add that the process of informed consent would serve to preclude this eventuality.

You can read the complete article and the authors’ conclusion here.

On one hand, it could be considered laudable that the AMA is willing to explore the pros and cons of this issue. But again, one must ask, as I did above, why is this even an issue? Does the AMA have no more pressing issues to which to devote its time? I could likely select any random healthcare professional who would be able to name ten, if not more, medical problems more important than transplanting uteruses into trans people. And I would be interested in seeing the number of trans people who are actively seeking this procedure. If, as the article asserts, the number of transgender people who would want such treatment is relatively low, why add to the load being carried by overburdened taxpayers and health insurance policyholders? While one may be born in a body not of one’s liking, surgical transition is a choice, as is adding a uterus to a body in which one did not previously exist.

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