Mandatory Sterilization for transgender people as a requirement of legal gender recognition struck down in Europe

Four years ago, nearly to the day, IJFAB Blog contributor Alison Reiheld wrote on the repeal of Swedish laws that had required transgender person to be sterile (or become sterile) AND to have surgical sex reassignment in order to change their gender on legal documents (“Transitions In Law: What Struggles Over Policy Changes Affecting Transgender Persons Reveal“).  This is important because discordance between legal documents and gender presentation is one way that trans persons are “outed.” It thus increases discrimination, harassment, and violence in every arena of life from commerce to housing to healthcare to marriage.  In addition, requiring these expensive, invasive, and life-altering procedures for persons who might not otherwise choose them treads dangerously into coercive practice.  It is thus a bioethics issue. In the case of Sweden, these laws were overturned in 2013.

Well, in case you missed it, in April of 2017, the European Court of Human Rights (ECHR) struck down mandatory sterilization for transgender people based on Article Eight of the European Convention of Human Rights: “everyone has the right to respect for his private and family life, his home and his correspondence.” The ruling was in favor of three French transgender citizens who were not allowed to change their names and genders on birth certificates without the required sterilization.  This ruling only directly affects France, where  the requirement had already been removed from statutory law. The ECHR has no authority to enforce the ruling in every European Union (EU) country, nor can it do so for the 47 countries which are signatories to the European Convention of Human Rights. These are non-identical sets: Turkey and Armenia have signed the European Convention but do not belong to the EU, which imposes additional human rights standards on nations. This ruling could, however, serve as a legal model for cases in other nations even though it is not binding on other nations. 20 Countries in Europe still require sterilisation for legal gender recognition, according to Transgender Europe’s (TGEU) Trans Rights Europe Map of 2017.

This image is color-coded to show which nations (20) in Europe require sterilization for legal gender recognition. They are Russia, Finland, Latvia, Lithuania, Georgia, Azerbaijan, Armenia, Turkey, Greece, Bulgaria, Romania, Serbia, Montenegro, Boznia & Herzegovinia, Slovenia, Slovakia, Czech Republic, Belgium, and Switzerland.

This image is color-coded to show which nations (20) in Europe require sterilization for legal gender recognition. They are Russia, Finland, Latvia, Lithuania, Georgia, Azerbaijan, Armenia, Turkey, Greece, Bulgaria, Romania, Serbia, Montenegro, Boznia & Herzegovinia, Slovenia, Slovakia, Czech Republic, Belgium, and Switzerland.

The ruling does permit nations to require mental health diagnoses or medical examinations before legally changing gender. Thus, it allows France to retain “gatekeeping” functions for medical and mental health providers; in Sweden, such gatekeeping has in the past meant that it can take as long as a decade to transition to the state’s satisfaction.  Such gatekeeping has itself been argued to be an undue barrier, and thus presents ethical concerns, especially as implemented in the past but still today.

We will see what changes in law, and in the lives of transgender persons, follow from the April 2017 decision by the ECHR.

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The Revenge Effects of Electronic Medical Records
Alison Reiheld

In 1996, historian of science Edward Tenner published his influential book Why Things Bite Back: Technology and the Revenge of Unintended ConsequencesIt is an extended consideration of how technology comes to demand much of us even as it frees us from demands. In it, Tenner introduces a concept that has come to be important in philosophy of technology: the revenge effect. Revenge effects are in play when a technology designed to alleviate a particular burden in fact imposes that burden. As Tenner puts it, “when a safety system encourages enough additional risk-taking that it helps cause accidents, that is a revenge effect.” This is an apt description of some of the consequences of Electronic Medical Records (EMR), also sometimes referred to as Electronic Health Records (EHR)

Tenner’s examples of revenge effects include the way that increasing computerization was intended to lead to a paperless office. Instead, at least during the 80’s and 90’s, it documentably led to even more printing because of the ease of producing printed versions with each revision. As Tenner makes clear, a significant factor leading to revenge effects is humans: when “we try to take advantage of some new technology, we may discover that it induces behavior which appears to cancel out the very reason for using it.”  Now, this is simply a “may.” Tenner is by no means arguing that all technology will have such revenge effects. However, he makes compelling case that it often does.

This conceptual framework has helped me to think through an issue highlighted by those of my medical ethics students with decades of experience in medicine, nurses and others who have practiced through the transition from paper to electronic medical records. This transition was mandated in the United States by the American Recovery and Reinvestment Act, to take place no later than January 1, 2014; not all systems talk to each other and not all are created equal, nor do all institutions incorporate them into care in exactly the same way. In a recent discussion by some of my students, several nurses with such experience noted that they seem to spend as much time maintaining the medical record as they do with patients, and that they perceive the EMR as taking them away from their patients.

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Time to Update IJFAB’s Pronoun Conventions?
Kathryn MacKay

In light of recent controversies in philosophy surrounding how philosophers ought best to write about vulnerable social identities–whether gender or race–I’ve been thinking about some things. Many things, many of which I will not get into here. One of them is the lack of representation in philosophy of trans people, people of colour, and trans people of colour (perhaps especially). It is productive that we are now discussing the dearth of scholarship and faculty positions held by trans people in philosophy. In this post, I exclusively want to discuss something that has been bugging me for months, but which now seems, if not urgent, then at least extremely topical: pronouns.

A few months ago, I was working with the copy editor at IJFAB because I had a paper accepted for publication and my manuscript needed to be worked up to fit the journal’s style conventions. My paper, like all my work, had been written without the use of gendered pronouns. As part of my commitment to encouraging recognition and greater acceptance of gender as non-binary, I use third-person plural pronouns in the third-person singular position. The Merriam-Webster dictionary calls this ‘the singular they,’ and some journals and newspapers have adopted its use as standard. IJFAB Blog, itself, has discussed this issue previously.

Using the singular they, for those who aren’t used to it, can result in some awkward sentence constructions. For example, I would have no problem saying in conversation or writing the following phrase: “I saw my friend, Chris, on the street today, and they were wearing yellow trousers.” For some, the combination of ‘my friend, Chris’ and ‘they’ is confusing and disruptive. I acknowledge this. However, I think that a little awkwardness is a reasonable price to pay for greater gender inclusivity in our speech and writing.

IJFAB has not yet adopted this convention. As a result, I had to change all of the instances of sentence constructions like the one above in my manuscript to he/she, or pick a pronoun to go with (most often, ‘she’). This bothered me, and not because it was a hassle. It bothered me because as THE journal of feminist bioethics, I expect IJFAB to be on the leading edge of feminist and (bio)ethical issues. IJFAB should be leading the way in gender inclusiveness, not holding on to the ‘old school’ of grammar or other conventions.

One thing we can learn from the recent storm in philosophy is that we, as in those of us with privilege and especially those of us in the establishment, need to work harder to create the space for diverse voices. I propose that we encourage IJFAB, our beloved journal, to update its style guide, and make a move toward non-binary gender inclusivity by adopting the singular they.

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Body Ecology and Commodification in The Handmaid’s Tale
Rebecca Bratten Weiss

Editor’s Note: This is one of several blog entries on Atwood’s The Handmaid’s Tale. For the first in the series, go here.

The Handmaid’s Tale was one of many texts which, when I finally read it, turned out to be very different from what right-wing religious educators had led me to expect. Extrapolating from muttering (male) disapproval, I had conjured vague and terrible antics of “sexual revolution,” women tearing themselves away from virtuous domesticity, turning on Christianity, probably taking the Pill and having abortions and, worst of all, enjoying sex too much.

Obviously, nothing at all like Atwood’s novel, in which the protagonist is subjected to depersonalizing, utilitarian sex as a kind of stand-in for her master’s infertile wife, her sexuality commodified not for pleasure but for reproduction, in a politically mandated surrogate motherhood which entails the utter erasure of the woman as anything other than a reproductive function. Her past relationships are wiped out, her real family torn apart.

She is the victim of a sexual assault that is no less heinous for being legal, and for the purposes of reproduction instead of sexual frisson. Sex is presented in this story as potentially frightening, and not in an orgiastic context, but in a relation of utility.

(We women always knew that it can be frightening, in this context).

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Pregnancy and Childbirth for Mothers with Disabilities

Every once in awhile a venue surprises you: Teen Vogue has been doing good critical reporting on social justice issues and American politics, and Cosmopolitan–long the home of beauty tips and how to please your man–has just published an article called “The Insulting Childbirth Experiences Mothers with Disabilities Endure.”

Author Kathryn Joyce interviewed a number of women with disabilities who are also mothers, but the focus of her article is the story of Nikki Villavicencio and her partner, Darrell Paulsen. Nikki uses her feet to perform tasks instead of her arms, since her arm joints are immobilized by arthrogryposis; Darrell has cerebral palsy. Both often use wheelchairs as mobility assistance.  After childbirth, their newborn infant Alexandria was transferred to a children’s hospital across town due to worrisome symptoms:

The staff at the children’s hospital complained that their wheelchairs took up too much space in the exam room, and a social worker told them the staff were only there to care for Alley, not her parents. The nurses also made it clear they would not help Nikki breastfeed. (Nikki remembers thinking, We didn’t want you to, but OK.) They even suggested Darrell wait in a separate room, down the hall.

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Not a desire which anyone may gratify: what impact might artificial wombs have on abortion?
Alison Reiheld

Amidst the flurry of news in the last week over artificial wombs–a primitive artificial placental sack, or “biobag”, sustained sheep fetuses for four weeks–most of the coverage focused on the value in caring for premature infants.

A hairless sheep fetus in a large plastic bag is depicted. Fluids and a pump mimicking placental blood flow are shown attached.

For a higher-resolution version of this image, Google the Scientific American article, “Brave New Wool.”

I was reminded of Judith Jarvis Thomson’s famous argument on abortion. In that argument, Thomson argues that it is wrong to compel a woman to carry a pregnancy to term against her will, especially if there is a threat to her life, by drawing on an analogy to a very ill violinist to whom you have been attached as life support against your will. The violinist example helps Thomson to discuss the limits of what women can be forced to do in order to render aid to others, rather than focusing on whether the fetus is a person; after all, uncontroversially (one hopes!) violinists are persons. Thomson says, “you may detach yourself even if it costs him his life.”  But Thomson goes on to say “you have no right to be guaranteed his death, by some other means.”  Or in other words, “the desire for the child’s death is not one which anybody may gratify, should it turn out to be possible to detach the child alive.” It is this last bit that was very much in my mind, along with the much touted benefits to premature infants, as I have reflected upon this technology.

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What Now?
Rory Kraft

EDITOR’S NOTE: Bioethicist Rory Kraft brings us this handy explanation of the complicated legislative processes in the U.S. Congress, and offers some recommendations for ethicists’ involvement in American healthcare reform going forward. For Kraft’s previous IJFAB Blog reflections on health care reform see this and this.

Last week, the U.S. House of Representatives passed the American Health Care Act (AHCA) 217 – 213. The bill now goes to the U.S. Senate.  For anyone who managed to miss the vote, no Democrats voted for the bill; Twenty Republicans voted against it (there are currently four vacant House seats; Republican Dan Newhouse of Washington state did not vote).

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A Plea to US Citizens: Contact your Senators about the current attempt to Repeal the Affordable Care Act without an adequate replacement
Rory Kraft

EDITOR’S NOTE: Earlier this afternoon, the U.S. House (one of the chambers of America’s bicameral legislature) voted 217-213 to approve a bill to repeal major parts of the Affordable Care Act, AKA Obamacare. The measure that cleared the House will then have to clear the Senate, which may have to make changes to the bill to get it to pass. If it passes, the altered bill will have to go back to the House for approval, a process known as ‘reconciliation’. The House voted on the measure–an adapted version of their March attempt–without the complete analysis of its impact from the Congressional Budget Office, an analysis they generally look for on this kind of bill. The White House defended voting without the CBO report, saying that the bill contains too many unknowns for the office to successfully predict its effects. Philosopher and medical ethicist Rory Kraft brings us this brief consideration of the measure that passed the House today. For his cautionary notes about prior attempts, see his March 31 blog, “The ABCs of the AHCA: A is for abortion, B is for backward, C is for costly.”

I do try to strike a certain balance on political posts. While I don’t try to “hide” my positions, I also generally do not find discussions of politics on social media to be time effective. Thus, I tend to share news stories with interesting angles more than stating my own position or calling for action.

Today I will make an exception and ask folks to take political action.

Please call your Senators and ask them to vote against the AHCA and in particular this alteration of the ACA.   You can contact your Senator by looking them up on this site.

If you fall on the liberal side of political issues, it probably doesn’t take a lot to convince you that bill will be detrimental to the nation’s health.

If you fall on the conservative side, you may be interested to know that under the Upton amendment $8 billion dollars will be funneled into trying to prop up the individual markets, while still causing a loss of coverage for some 24 million people. This is not fiscally conservative. This is not compassionate conservatism. AND, members of Congress and their staff will be exempt from the changes that AHCA would bring to both Medicaid coverage and to the nature of employer-based coverage, including pre-existing conditions.

There is no question that there are aspects of ACA (“Obamacare”) that should be revisited and fixed. The AHCA does nothing to fix those problems.

Call your Congressman/woman and urge them to vote against this bill and bring forward a real approach to repair ACA.

Appendix from the Editor: You can learn more about this through the following links, all dated May 4, 2017.


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Labor Without Respite: Tennis, pregnancy, and other ‘unexpected feats’

This image shows a woman with pale skin and long blonde hair. A bookshelf is behind her as though the picture is taken in a professional office. She stares seriously at the photographer.

Verina Wild

A black and white photo of a woman with short wavy dark hair. She is wearing earings shaped like leaves and a pair of rectangular wire framed glasses. Her mouth is slightly open in a very small smile as though she is listening and about to speak.

Agomoni Ganguli-Mitra


Agomoni Ganguli-Mitra (Dr. sc. med., Research Associate, Liminal Spaces Project; Teaching Fellow, School of Law; Executive committee member, Mason Institute; University of Edinburgh Law School, UK)

Verina Wild (Dr. med., Philosophy Department, Ludwig-Maximilians- University Munich, Germany) 

This image shows the head and upper torso of tennis star Serena Williams. She is wearing tennis clothes in black, a black head band, a delicate silver necklace and a white watch. She covers her mouth with her hand, as if in astonishment.

Social media feeds are currently lighting up with news from Serena Williams and her first pregnancy. Articles are also picking up on the detail that given that the world class athlete is 20 weeks pregnant, she must have won the Australian Open in her first trimester. If you accept the fact that bodies of super stars, especially in relation to pregnancy, are a matter of public debate – so far, so good, for some happy news amidst otherwise rather unbearable headlines.

A particular piece in The Guardian however, gave us pause. The Guardian asked its female readers what ‘unexpected feat’ they ‘pulled off’ while pregnant.

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The Handmaid’s Tale: a roundup of media sources and related prior IJFAB Blog entries

Editor’s Note: See “Body Ecology and Commodification in The Handmaid’s Tale” by Rebecca Bratten Weiss, and more to come.

Over the next few weeks, IJFAB Blog will have several original blog entries on The Handmaid’s Tale, both the book and the new Hulu series that just began releasing episodes online Wednesday April 26, 2017. Until those are in and posted, this Editor provides a list of thought-provoking reflections on the book and the series from the general media:

IJFAB blog has also had previous blog entries that address the general issue of control over women’s reproduction and the social importance of reproduction:

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Sleep as a matter of justice

Over at the LA Times, Benjamin Reiss has a fine consideration of the ethical importance of sleep differences in his article, “African Americans don’t sleep as well as whites, an inequality stretching back to slavery.”

Poor sleep has negative health effects, and is more likely to result from having to live in certain circumstances: during times of slavery there were tight and crowded sleeping quarters while sometimes chained and women were particularly prone to sexual assault, and now there are unpredictable work shifts for lower-income workers who must live in more crowded circumstances in order to live more cheaply.  Vulnerabilities of race and class are compounded. I won’t summarize large portions of the article here, but I strongly recommend that you follow the link above to this thoughtful, beautifully-written piece that examines many parts of American history with respect to sleep and slaver including the role of medicine and medicalization in reinforcing differences in treatment of blacks and whites that affect sleep.

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Like and unlike: Late abortion in the case of wanted pregnancies, and miscarriage
Alison Reiheld

A recent article by Natalia Megas in The Guardian profiles three women who chose late abortions and who had very much wanted to be pregnant.  It is a moving exploration of the seriousness of abortion as a moral issue, and an important set of premises in why late abortion must remain legal and available. It also raises questions for me about whether the experience of late abortions of Yellow square bearing the words "A wanted pregnancy as much as a dreaded pregnancy can play differently than all one's previous imaginings. --Susie Orbach"wanted pregnancies shares elements of experiences of miscarriage, not just termination of unwanted pregnancies. But let’s start with real narratives from Megas’s article.

Early in the article, Dr. Jennifer Conti explains why women often must make such a decision:

Abortions that occur at this stage in pregnancy are often the result of tragic diagnoses and are exactly the scenarios wherein patients need their doctors, and not obstructive politicians… Asking a woman to carry a fatally flawed pregnancy to term is, at the very least, heartbreaking. I’ve often heard women say that they chose to end such pregnancies because of unselfish reasons: they couldn’t bear the thought of putting their fetus through even more pain or suffering.

One pregnant woman’s* fetus** had multiple congenital deformities which might cause the fetus to die during labor, caused complete or partial absence of the connection between the brain’s Continue reading

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