The war over the womb 

The womb, that secretive house of early life, is coming under the spotlight. For a long time it was scarcely mentioned in public at all, save in obstetrics, gynaecology, DH Lawrence novels and the Bible. In recent years, however, the uterus has attracted the dubious attentions of the ‘wellness’ industry: Gwyneth Paltrow even recommended ‘cleansing’ it by sitting over a machine pumping out ‘mugwort steam’. And now a new book by the writer and midwife Leah Hazard – Womb: The Inside Story of Where We All Began – looks at this shape-shifting organ from all angles: medical, emotional, political and futuristic. What emerges from her examination is fascinating, contentious, and potentially chilling – as she looks ahead to a future in which the womb, as we understand it, may gradually become redundant. 

For now, however, it remains a natural phenomenon: a wilier, grabbier and more dynamic organ than many might have suspected. During female orgasm, for example, the uterus reacts with rhythmic contractions to pull sperm ‘inwards towards any potential egg’ lying in wait. With pregnancy, it can expand from the size of a pear to a watermelon. Recent research has also suggested that outside of its reproductive purposes, the womb appears to be in regular, mysterious communication with the brain: experiments in rats found that those with their uterus removed had much greater difficulty – six weeks post-op – in navigating a maze than those who retained it.  

The womb has long been disputed territory, at the centre of a battle for control between men and women, the state and the individual. As the site of human gestation, it inevitably draws outside interference. Sometimes – as in a number of US states today – the law will demand that it carries a foetus to term, even in cases of rape or incest. At other times, however, the law has imposed the womb’s redundancy or removal against its owner’s will. One chapter, ‘reprocide’, delves into the dark history of forced sterilisation and hysterectomies. In the US in 1927, the heart-breaking case of Carrie Buck – the daughter of a drug-addicted prostitute who had herself been raped and given birth to a little girl – ushered in a grim new era of ‘state-sanctioned sterilisation’. The judge, Oliver Wendell Holmes Jr, pronounced that ‘three generations of imbeciles is enough’ and that the allegedly ‘feebleminded’ Carrie – whose school report cards in fact showed her to be of normal intelligence – should be forcibly sterilised.

There followed thousands of state-compelled sterilisations, including of women deemed promiscuous or ‘abnormally attracted to partners of another race.’ Nor has such ‘reproductive violence’ entirely vanished today, it seems: a current class action lawsuit in the US alleges that numerous immigrant women at the Irwin Detention Facility in Georgia were given hysterectomies without consent. 

Even for a comfortably-off young woman, used to high levels of autonomy and social equality, the reality of motherhood can come as a huge shock. Part of that is due to the heavy demands – and fierce joys – of responsibility for a new human being. But it’s also about experiencing a hitherto unimagined level of external judgement. The medical language surrounding pregnancy and miscarriage can be fraught with implied censure: when a womb doesn’t perform as expected, it’s described in terms such as a ‘hostile’ or ‘irritable’ uterus, rather as a moustachioed Victorian gentleman might chide a sulky wife.  

As reported through this midwife’s eyes, birth – ‘this assault on bodily integrity, this epic struggle, this bloody triumph’ – is often a messy, feral, high-stakes drama, which the novelist Rachel Yoder calls ‘perhaps the most violent experience a human can have apart from death itself.’ Medical interventions in labour – inductions, emergency caesareans, forceps deliveries – may save lives, but the manner and speed with which they are enacted can leave many new mothers traumatised, shorn of all control. Hazard makes a convincing case that with more time and thoughtful adjustments, the terror and joy of giving birth could be tipped more reliably towards the latter. But obtaining funding for the worthy work of female healthcare and research, she says, is like ‘drawing blood from the proverbial stone’. 

The real cash and cutting-edge technology, one feels, is focused elsewhere, on the rapidly changing landscape of what motherhood signifies and who can give birth. With the rise of IVF in combination with commercial surrogacy – legal in countries such as Ukraine, Mexico, Colombia and selected US states – the word ‘mother’ itself has splintered into several separate functions. The ‘biological mother’ is the egg donor, whose genetic material is being passed on to the child. The paid surrogate whose womb is carrying the baby is the ‘gestational carrier’ or the ‘birth mother’. The woman who performs the caring role of ‘mother’ as the child grows up may be the same as the ‘biological mother’ or a different woman. Or this ongoing maternal role may be dispensed with completely, now that single men in US states such as California can legally purchase the temporary services of an egg donor and a surrogate – at a cost of around $100,000 – with a view to raising the baby alone.

As Hazard’s book emphasises, pregnancy and birth are gruelling, sometimes risky processes. Yet although hardly discussed here, commercial surrogacy raises multiple ethical questions. Is it morally defensible to allow wealthy men and women to rent the wombs of poorer women, or should some aspects of our existence remain beyond the grasp of the market?  

For decades now, too, innumerable books and newspaper articles have been written about the potentially negative effects on children, particularly boys, of growing up with single mothers and absent fathers. But what a mother mustn’t do, she is widely given to understand, is flee the family herself. Across cultures, mothers are depicted as the family anchor, the person with whom the buck of parenthood ultimately stops. Yet now that technological advances and a hungry market have joined forces, rising numbers of infants will grow up motherless not by accident but design, something that has generated comparatively little public discussion. The mother is indispensable, it seems – until, suddenly, the market decides she isn’t. 

A further advance in medical science is already here, albeit in its early days, and its future applications will have even more implications for what motherhood means: the uterus transplant. Hazard interviews Jennifer Gobrecht, a woman born without her own womb, who was able to give birth to a baby boy using a womb from a dead donor. The organ was then removed after it had served its purpose, since to retain it would have meant long-term use of complex anti-rejection medications with side effects.

Scientists are now exploring the possibility of taking this further, and ‘transplanting wombs into bodies with physiologically male characteristics.’ Indeed, the authors of a cited 2019 report argue that ‘it may in fact be immoral’ to exclude transgender women ‘from the possibility of gestating and birthing children.’ Hazard is relaxed about this, wondering whether giving reproductive options to people, including ‘anyone with a uterus and anyone who wants one – can be such a bad thing?’ Little space is afforded to the counter-argument: the potential ethical drawbacks of implanting a female organ in a biologically male body, at medical risk and vast expense, in a world in which millions cannot afford the most basic healthcare. 

It was on this culturally inflammable territory of trans medical treatment that I sometimes sensed the author colliding with the logic of her other findings, but choosing to skate blithely onwards. She has established, for example, that the womb is a complex organ which delivers valuable cognitive benefits. With the exception of cases in which it’s linked to disease and debilitating suffering, the strong medical advice is ‘if you have a healthy uterus, you should keep it for as long as you can.’ The exception to this rule, the author argues confidently, are some trans men, for whom the ‘social and emotional benefits’ of hysterectomy ‘far outweigh’ the loss. One, called Ryan, describes himself as broadly grateful for his hysterectomy – which was ‘freeing’ – although ‘the grief for his fertility’ still blindsides him at unexpected moments: a more nuanced assessment. 

Although Ryan feels, overall, that things have worked out well, a couple of experts are cited bemoaning that the medical pathway is currently over-crowded with gatekeepers, and should become faster and easier. Dr John Chisholm CBE, chair of the BMA’s Medical Ethics Committee, testified at a 2021 inquiry into reform of the UK’s Gender Recognition Act that ‘it’s very onerous and dehumanising to have to be asked all these intrusive questions in order to prove, in essence, that you are who you say you are.’  

But things aren’t that straightforward, surely. In the case of trans men, removal of a healthy womb and the permanent loss of fertility both weigh heavily on the negative side of the ‘first do no harm’ scales. And while ‘you are who you say you are’ does indeed remain consistent for many trans people, for others it changes: hence the case of Michelle Zacchigna, 34, a detransitioned woman who is currently suing eight Ontario healthcare providers for giving her testosterone, a bilateral mastectomy and a hysterectomy during what she now says was a mental health crisis. A raft of similar lawsuits are in the pipeline. Given that international dissent on best practice is growing, along with an evidence base that the BMJ recently described as ‘under construction’, one might imagine a careful, highly individualised approach would make more sense than fast-tracking surgery.

This book provides ample historical evidence of both legal and medical authorities displaying a reckless enthusiasm for hysterectomy of healthy wombs, based on fashionable theories at the time. Unfortunately, it doesn’t reassure me that they’re always getting it right now, even if blatantly coercive practices have been replaced by something more complex. Still, looking even further ahead, there may come a time when the messy mechanics of pregnancy and birth are detached from the female body entirely. The race is on, the author says, ‘to develop a functional, lab-grown uterus.’

They began with lambs: in 2017, researchers in Philadelphia ‘safely nurtured extremely preterm lamb foetuses’ equivalent to human ones on the edge of viability. While ‘the ability to gestate a human foetus outside the womb from conception to full-term birth may yet be decades away’ science undoubtedly has that goal in its sights. Hazard sketches a scenario in which ‘midwives in this new age of biobags’ are more like ‘lab technicians’, and ‘birth as we know it’ is considered little more than ‘a quaint practice of primitive people.’ It’s a potentially unsettling notion, she admits, akin to the jars of foetuses in Aldous Huxley’s Brave New World. Yet perhaps these ‘novel womb technologies’ would be freeing, as certain philosophers suggest, liberating women from the shackles of pregnancy?

Such liberation has potentially deep traps. The intensely protective bond between mothers and babies, particularly in their earliest days, derives partly from the fact that the mother has gestated the child and is awash with bonding hormones: even in commercial surrogacy, that fundamental ownership must be pre-negotiated away. But to whom will babies belong, once grown in a biobag? Anyone who has commissioned them, I expect, perhaps even including dystopian states.

In the past, authorities have found ways to remove or rob the womb (those shamed, tearful girls in 1950s and 60s mother-and-baby homes, coldly coerced into handing over their babies for adoption). Now the market has discovered a way to rent the womb out. And in the future, scientists seem ambitious to relocate it or replace it entirely. This last innovation could extinguish the one certainty in every human life, apart from death: that we are all born from a mother. And a mother may be humanly fallible, occasionally even disastrous, but for most people she’s the best shot we’ll get at being unconditionally loved. Many of us, invited to marvel at the prospect of her technological erasure, will instinctively voice our deepest unease, like the hopeless proles in Orwell’s Nineteen Eighty-Four, who – confronted by some new horror – could only protest ‘they didn’t oughter’.