What are the Possibilities of Uterine Transplantation in Transgender Patients?

Currently, there are heated discussions about the linguistic limitations of thebinary gendermodel for the representation of the various forms of gender expression. In Anglo-Saxon countries, the possibility of using gender-neutral articles and pronouns is being discussed, while in our Brazilian population, the gender derivation vowel of pronouns is sometimes substituted by the ‘@’ or ‘x’ characters. The proper nomenclature to refer to these people must respect the genre with which they identify themselves. Thus, when referring to an individual born with biological male sex and with female gender identity, we must use the term transgender woman. Not every transgender individual must necessarily undergo sex reassignment surgery. This must be a particular decision made by each individual in conjunction with the multidisciplinary team following the case, according to Resolution number 208/2009, of the Regional Medical Council of the State of São Paulo, Brazil. The Brazilian Unified Health System (SUS, in the Portuguese acronym), within the principles of universality and integrality, has regulated the necessary conditions for the process of sex reassignment by ordinance number 2836/2011. Nowadays, access to the sexual reassignment process and the adequate follow-up are themain challenges faced by the transgender population, which is estimated to be between 0.3% and 0.6% of the general population in the United States.1–3 The success of the first uterine transplantation recently performed in our country opens a new field of activity in the area of human reproduction. It may assist women with no possibility of becoming pregnant, such as those with congenital agenesis of the uterus, massive destruction of the endometrium after infected abortion, or those hysterectomized.4 However, we still have much to improve in this field before its consolidation as a concrete alternative for these women. The improvement of this technique should lead to the inevitable question about the possibilities of its application in contexts different from those initially imagined, that is, expanding it to transgender individuals. This hypothesis is certainly a broad question for many researchers. The only historical reference for attempted uterine transplantation in the literature was reported in Germany, in 1931. The transgender woman Lili Elbe underwent uterus transplantation and died after three months due to surgery complications. This fact brought repercussions and discussions both in academia and in the media. It was even portrayed in the film The Danish Girl (2015).5 Perhaps, this is a limitation of the technique for uterine transplantation. Transgender individuals have gender identity that is inconsistent with their biological sex. This disagreement can cause intense psychologic suffering, and has no correlation with preferences or objects of sexual desire. The individual feels dissatisfied with his/her own body, and this feeling is independent from the romantic relationship models experienced. In this scenario, there is a desire for complete transformation, including the possibility of procreation, which is a major dilemma with the existing technology. Reproductive rights are recognized as universal rights by the Brazilian legislation, including the LGBTT (lesbian, gay, bisexual, transsexual and transgender) population, who have specific rights of access to health as stated by law, among