Under the Gender Recognition Act 2004, an application for a gender recognition certificate must be granted if a Gender Recognition Panel decides that the applicant has—or has had—gender dysphoria; has lived with the acquired gender for 2 years before applying; and intends to live permanently in the acquired gender. According to the Gender Identity Research and Education Society (GIRES) (2011), in 2007 some 1500 people in the UK presented for treatment of gender dysphoria; by 2010 the figure was approximately 12 500. The number who present for treatment are part of a mainly invisible group of people that ‘may number 300 000, a prevalence of 600 per 100 000, of whom 80% were assigned as boys at birth.’ GIRES does, however, state that it expects that this balance may become more equal.
The midwifery profession may encounter increasing numbers of transgender individuals asserting their reproductive rights to have children. In response to this, the World Professional Association for Transgender Health (2011:51) advocates that, ‘transsexual, transgender, and gender non-conforming people should not be refused reproductive options for any reason’.
One of the most well-known people to undergo transition and pursue reproductive options was probably Lili Elbe (1882–1931), portrayed in the film The Danish Girl (2015). Einar Wegener not only underwent gender reassignment surgery to become Lili, but also received transplanted ovaries and a uterus, which proved fatal less than 2 years after beginning her transition (Beyrer, 2016).
Today, with the advent of successful uterus transplantation, Murphy (2015) considers whether there is any moral reason why men or transgender women should not be eligible for the same opportunity for gestation. He is clear that the research parameters of those involved in fertility medicine should not be constrained by the assumption that one's sex necessarily determines one's reproductive destiny.
In contrast, Lerner et al (2017) are more cautious, suggesting that the anticipated psychological impact of uterus transplantation on transgender individuals warrants greater debate and research. They conclude that ‘in the current stage of technical development, uterine transplant surgery should not be recommended for transgender women’ (Lerner et al, 2017:522).
While Sampson et al (2019) acknowledge that it is not technologically feasible to make uterus transplantation a safe and effective option for genetically XY women—which includes transgender women and women with complete androgen insufficiency syndrome (CAIS)— they contend that such women should not be excluded from participating in clinical trials. The challenges associated with this include addressing the need for genetically XY women to undergo a total vaginoplasty, entailing a greater infection risk if part of the intestine is used in the procedure. Transgender women and women with CAIS may also need surgical reshaping of the pelvis to accommodate an additional organ and future fetal growth (Sampson et al, 2019).
A further dimension is introduced by Murphy (2014), who considers synthetic gametes—sperm generated from female stem cells, and eggs generated from male stem cells—that have produced live offspring in laboratory animals. This would undoubtedly open several entirely new avenues for debate and may result in re-evaluation of how the labels ‘mother’ and ‘father’ are applied and to whom.
For some observers, this may be seen as an ominous prospect; however, whatever our views on transgender issues, it seems that one way or another, midwives will be drawn into the debate.