Is There a Doctor in the House?

Queering the medical ethics of pregnancy to problematize a desire for “normal fetal outcomes” is an abandonment of evidence-based medicine and the principle of “do no harm.”

Image Credit: Nature on iStock

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About the Authors

Jennifer Lahl (MA, BSN, RN) is President and Kallie Fell (MS, BSN, RN) is the Executive Director at The Center for Bioethics and Culture. They have produced several important documentaries that can be viewed for free on the Center’s YouTube channel. Follow them on Twitter: @JenniferLahl and @Kal_Fell.

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In recent years, a striking paradigm shift in medical ethics has emerged, driven by progressive political ideologies purporting to champion “Social Justice.” This shift has precipitated a surge in initiatives centered around diversity, equity, and inclusion (DEI). The resulting effects have varied considerably; they include the introduction of explicit racial bias in treatment protocols in a quest for “health equity,” and an unsettling disregard for biological sex as an important variable in both medical research and patient care. Instead, the new radical movement favors categorizing individuals based on their self-identified and medically irrelevant “gender identity.”

Even more alarmingly, we are witnessing a direct assault on the language associated with women’s health in medicine. Terms traditionally used in clinical settings, such as “mothers,” are being replaced with neutral alternatives like “birthing parents.” Similarly, the term “women” is frequently substituted with “individuals with a cervix,” even though nearly half of women don’t know what a cervix is and such language may therefore cause a significant number of women to forgo important routine cervical screenings.

This trend of overlooking biological sex as a critical medical variable stems from an ideological drive to “queer” the natural world. The proponents of this view resist categorization, arguing that such practices are instruments of oppression wielded by the powerful against the less powerful. According to this perspective, medicine must eschew not only biological categorization of patients, but also traditional notions of what is deemed desirable or adverse patient outcomes.

These ideological shifts have raised substantial concerns regarding potential harm that such denial of biological realities could inflict on patients. However, recent academic discourse has escalated these concerns to new levels. A provocative new paper in the journal Qualitative Research in Health titled “Medical uncertainty and reproduction of the ‘normal’: Decision-making around testosterone therapy in transgender pregnancy” by Pfeffer and colleagues propels us further down the road of medical malpractice.

The authors, a group of transgender sociologists and enthusiasts, and healthcare activists, with not one medical degree among them, argue to dramatically move the goal posts of medical ethics, choosing to completely disregard the health, safety, and well-being of the developing fetus, all in the name of “trans” inclusion. Abiding by their paper’s guidance would land us in a vacuum devoid of medical ethics and a seismic shift away from the importance of scientific research and medical evidence in favor of activist directed healthcare.

The authors argue that “gendered” pregnancy care is too focused on helping women have healthy babies, and that it might be okay for transmen to continue taking testosterone during pregnancy despite the known health risks to the fetus and effects on its normal development. The desire for “normal fetal outcomes,” according to the authors, is rooted in a problematic desire “to protect their offspring from becoming anything other than ‘normal’” and “reflect historical and ongoing social practices for creating ‘ideal’ and normative bodies.”

This is, quite frankly, insane.

In the paper, Pfeffer et al. maintain that:

[L]acking and uncertain medical evidence (HRT with testosterone during pregnancy and chest feeding) in a highly gendered treatment context (pregnancy and lactation care), both patients and providers tend to pursue precautionary, offspring-focused treatment approaches.

We argue that medical ethics exists to guide medical providers and protect both the expectant mother and her future offspring.

The authors of the article strive to underscore the prevailing power dynamic and expertise discrepancy between medical professionals and their pregnant patients. They also highlight “lack of training on trans pregnancy care,” and the failure of the current “precautionary approach” within a “highly-gendered space of pregnancy care.” However, conspicuously absent is any robust, concrete data to substantiate their claims. Instead, they bolster their argument by cherry-picking quotations from their study involving a pool of 70 international “trans” individuals and 22 “health care providers who self-identified as focusing their practice with trans populations.”

Before continuing, we must point out the obvious flaw in the article: pregnancy care isn’t “gendered,” it’s sexed. Only the biologically fertile human females of our species possess the physical attributes necessary for pregnancy and childbirth. This is a simple biological reality.

Let us now turn our attention to the role of a physician in caring for a pregnant woman and the developing fetus.

The doctor-patient relationship is sacred, considered to be the core element in the ethical principles of medicine. Medicine’s practice, at its heart, is a moral undertaking, thus conferring upon the physician the fiduciary duty of ‘primum non nocere’—first, do no harm. In the seminal work Principles of Biomedical Ethics by Tom Beauchamp and James Childress, they delineate the four fundamental principles of medical ethics, often known as the “Georgetown Mantra”:

• Beneficence: the duty to “do good”

• Non-maleficence: the duty to “not do bad”

• Respect for Autonomy: respecting a patient’s right to self-determination

• Justice: the principle to treat all people equally and equitably

In the context of pregnancy, the physician must uphold these principles towards both the mother and her unborn child(ren).

The authors of the new paper are quick to point out the power and expertise imbalance between doctors and patients. This is neither a new nor concerning arrangement. Firstly, it is expected and indeed desirable that our physicians possess deeper knowledge and expertise in the field of medicine. We seek their counsel precisely because of their expertise, and in matters of pregnancy, we particularly rely on those with training in midwifery or obstetrics and gynecology. When complications arise during pregnancy, we consult specialists trained in managing high-risk cases or practitioners of maternal-fetal medicine.

Secondly, women are keenly aware of the potential power disparities, or injustices, that exist in medicine, notably in obstetrics and gynecology. This field, with historical roots in unethical practices and racism, often compels women to forego modesty and disclose their vulnerabilities. But one doesn’t need to enter a maternity ward to understand the difference between how men and women are treated in medicine. Generally speaking, women are often not accorded the same degree of seriousness as men in healthcare, particularly concerning pain. Research has shown that women’s pain and suffering are more frequently dismissed or misdiagnosed, especially among women of color. Instances of women being prescribed sedatives instead of pain medication, and misdiagnoses during heart attacks, are sadly commonplace.

A recent episode of The Retrievals, a podcast by The New York Times, titled “The Patients,” unveiled startling experiences of women at the Yale fertility clinic who underwent intense, unexpected pain during egg retrieval procedures. These women recount how “their pain was not taken seriously” and “they were not believed.” It emerged that a nurse at the clinic had been illicitly swapping fentanyl for saline. Even after this revelation, the center seemed to downplay the harm and pain suffered by these women, who had endured excruciating medical procedures with saline salt water as a substitute for anesthesia. These imbalances and injustices are not isolated to “trans” patients and should not be co-opted as a rationale for altering medical guidelines or evidence-based care, especially regarding the most vulnerable among us—the unborn child. Rather, these disparities should move medical professional societies, such as the American Congress of Obstetrics and Gynecology (ACOG) and the Endocrine Society, to uphold the highest standards of medical practice, grounded in empirical evidence and biological fact, irrespective of a patient’s sex.

The cornerstone of a patient’s trust lies in their belief that their physician’s recommended treatment plan will consistently be informed by these four core principles of medical ethics outlined above.

The concerns raised by Pfeffer and colleagues focus on the modern treatment approach physicians take, which they deem excessively “precautionary” and “offspring-focused.” Fortunately, caring for the child and the mother are neither mutually exclusive nor zero-sum. In situations where a woman aspires to become pregnant and commits to motherhood, physicians can provide care that optimizes outcomes for both parties while minimizing potential harm. If a woman chooses to continue a pregnancy, doesn’t the developing fetus also have a right to the four principles of medical ethics? In such cases, the physician is duty-bound to care for both the child and the mother. There will of course be circumstances when the mother may need to cease a particular medication or treatment to safeguard the fetus, and the physician must provide comprehensive counsel to the family, elucidating the risks and rewards involved for both the mother and the vulnerable life developing in utero.

One doesn’t have to look hard to find a list of drugs and substances that are known to be harmful to a developing fetus. Yet, for numerous other substances, safety remains indeterminate due to insufficient research. Pregnant women participating in clinical trials present intricate ethical challenges, potentially subjecting unborn babies to an array of unanticipated iatrogenic issues. Further, scientists might be hard-pressed to find a mother who would be willing to risk the health of her unborn child to advance scientific or medical understanding. Given the nature of the type of research that would be needed to satisfy the safety threshold for women remaining on their high dose testosterone throughout their pregnancy and breast-feeding period, we can again imagine a very small subset of pregnant women who would be willing and eligible to participate in this research endeavor.

This raises serious questions: Should we allow unborn children to be the subjects in medical research? Should we allow breastfeeding, newborn infants to be subjects in clinical trials? This concern is highlighted in the statement of a participant from the study under scrutiny, who pondered, “If I take testosterone, will that reduce my milk production? Will it transfer to my kid? I don’t know. Again, we don’t have any information on that because nobody lets cis women take testosterone and breastfeed” (emphasis our own).

Current research is already probing the effects of testosterone on breast milk production and its impact on breastfeeding infants. One unsurprising preliminary finding suggest that elevated testosterone levels adversely affect milk production. The La Leche League notes that “testosterone interferes with the hormone necessary for lactation (prolactin) and can cause a significant decrease in milk supply” and may shorten the the length of time a baby is able to breastfeed and increases the amount of formula supplementation.

Presently, testosterone is classified as a teratogenic, US FDA pregnancy category X drug, suggesting it can induce birth defects. It is labeled as such because “studies in pregnant women have demonstrated a risk to the fetus, and/or human or animal studies have shown fetal abnormalities; risks of the drug outweigh the potential benefits.”

It is well-established that prenatal exposure to androgens, such as testosterone, can cause genital defects in females. Androgens act as masculinizing hormones, guiding the formation of male genitalia and inhibiting the development of a vaginal opening in males. Consequently, medical practitioners are not displaying “cisnormativity and judgement” in their handling of “trans” patients regarding testosterone “therapy”; they are fulfilling their ethical duties of beneficence and non-maleficence. Given the known effects of testosterone on a developing fetus, a conservative, precautionary approach is duly warranted.

Before moving on, we would like to provide a direct quote from a woman taking testosterone that Pfeffer et al. highlight in their article:

There’s a bunch of research around androgen exposure in utero and intersex conditions…I did have a little bit of a complex feeling around working hard to not have an intersex child… As someone who is gender ‘other,’ to work hard to not create a different body that is gender ‘other,’ it feels weird. It feels a little hypocritical. But it kind of came down to wanting the child I created to have the most options in their own body in their own life which most intersex folks don’t have fertility open to them.

It’s essential to differentiate between being intersex and being transgender. Intersex variations or differences in sex development impact an individual’s chromosomes, genitals, hormones, reproductive system (including the gonads), and their entire life. Research shows that intersex adults experience significantly more health issues and are more likely to report physical health limitations than those without intersex variations. These are serious considerations for both expecting mothers and healthcare providers.

When considering the experimental nature of women who are on high-dose testosterone while pregnant, we concur with the authors that there is a scarcity of evidence and studies, but this is largely because this is unchartered territory. Safe and ethical methods to study, track, and monitor this demographic are lacking, as is a substantial sample size necessary to collect meaningful data. Putting the fetus aside for a moment, we currently have no data on the effects of testosterone on the pregnant woman herself, specifically a pregnant woman with gender dysphoria.

For those who wish to become pregnant, taking testosterone can be problematic. As indicated by Planned Parenthood, “some trans men’s ability to get pregnant might decrease after taking testosterone for a while,” in some cases halting ovulation entirely. In such instances, stopping testosterone may be necessary to conceive. For those who managed to conceive while still on testosterone, the NHS website recommends pausing testosterone usage during pregnancy and that pregnancy itself could trigger mood fluctuations and exacerbate feelings of “gender dysphoria.”

Pfeffer and colleagues write that most participants in their study use testosterone “as a critical medically managed component of their transition” and that there are concerns and fears about pausing testosterone prior to or during pregnancy and the postpartum period. Specifically, pausing testosterone would make “public recognition as a man more challenging” and might increase body dysphoria and depression, including postpartum depression. We have to stop here, rub our eyes, and shake our heads. Why would someone wanting to pass as a male desire to take on the very female task of pregnancy? Not only that, but none of the stated concerns or fears of stopping testosterone during pregnancy, postpartum, or while breastfeeding are life-threatening or permanent conditions. There are ways to safely manage depression and body dysphoria that don’t involve potentially harmful compounds.

Pregnancy, postpartum, and breastfeeding are stages known to be associated with dramatic hormonal shifts. Physicians must consider these factors when counseling a patient who is also taking exogenous hormones, like testosterone. The effects of external testosterone on the female body during pregnancy, postpartum, and breastfeeding remain unknown.

It seems that at least one of the the doctors interviewed agreed:

I think if you choose to have a pregnancy and your female hormone levels would be already so high that testosterone probably wouldn’t even mentally help… if you’re producing breast milk and you couldn’t be without testosterone for mental health… if you couldn’t deal without testosterone, then you probably shouldn’t be pregnant.

Upon reviewing the treatment approach proposed in the article, it’s clear that the authors lack a nuanced understanding of medical ethics and the principles of evidence-based medicine. They offer a distorted interpretation of the four basic principles of medical ethics and their application to patient care. If a “trans man” seeks to conceive and bear a child, the physician is obligated to safeguard both patients—the parent and the fetus.

The authors’ suggestion that medical providers should deviate from the principle of “do no harm” to follow paths where the evidence indicates harm is quite shocking. This perspective, driven more by ideology, emotions, and personal desires than by evidence, conflicts with the foundations of evidence-based medicine.

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