Gestation as mothering

Some commentators maintain that gestational surrogates are not ‘mothers’ in a way capable of grounding a claim to motherhood. These commentators find that the practices that constitute motherhood do not extend to gestational surrogates. We argue that gestational surrogates should be construed as mothers of the children they bear, even if they fully intend to surrender those children at birth to the care of others. These women stand in a certain relationship to the expected children: they live in changed moral circumstances by reason of their pregnancy, and they engage in the practices said to define motherhood in the post-birth context. By contrast, ovum donors and embryo donors are not similarly ‘mothers’ because they do not find themselves involved in these circumstances. Not all women involved in three-parent in vitro fertilization qualify as mothers either. Given this analysis of mothering, we note that transmen who gestate children are engaged in mothering activity even if they otherwise function as a father to those children. By itself, this defence of the maternity of gestational surrogates does not confer moral title to the children they bear; gestation would not by itself override the contractual arrangements gestational surrogates have made regarding the disposition of their children. This interpretation of gestational surrogates as mothers does, however, undercut cultural understandings of these women as mere ‘vessels’, devoid of entitlement to respect as persons and parents. We also consider the meaning of mothering for ‘brain-dead’ women kept alive to give birth and for the prospect of extracorporeal gestation.     

Gestation length in Tarsius bancanus

A gestation length of 178 days was determined for Tarsius bancanus based on a vaginal smear containing whole sperm. This value replaces the only previously reported information on gestation length in tarsiers, a rough estimate of approximately 6 months for T. syrichta.     

Gestation length in rhesus macaques (Macaca mulatta)

We describe some of the sources of variation in gestation length among rhesus macaques. the data were obtained from the timed-mating breeding program at the California Regional Primate Research Center (CRPRC). Information about approximately 700 pregnancies that resulted in spontaneous vaginal deliveries of liveborn young is presented. The average length of these pregnancies was 166.5 days. In this population, older females with higher parities had significantly longer pregnancies and significantly heavier infants than other females did. Other factors, including infant sex, month of conception, maternal reproductive history, and paternal identity, had no consistent effect upon gestation length.     

A Review of Breast Development in Cisgender Women and Implications for Transgender Women

Objective: The objective of this article is to describe the hormonal pathways required for breast development in cisgender women and to review the current available literature describing breast growth and breast cancer risk in transgender women.Methods: Literature review and discussion.Results: Early mammary tissue development occurs prenatally. This process is hormone-independent and occurs similarly in males and females. Breast tissue is quiescent until puberty, at which time surging estrogen levels in cisgender girls mediate breast development and growth. Adult breast tissue composition further evolves in cisgender women during pregnancy, lactation, and menopause, revealing the ever-changing interplay between breast structure and hormonal environment.Conclusion: Breast growth is a significant physical endpoint in the hormonal treatment of transgender women. Transgender hormone regimens, which typically pair an estrogen with an anti-androgen, can help achieve this goal.     

Splitting the Difference? Principled Compromise and Assisted Dying

Compromise on moral matters attracts ambivalent reactions, since it seems at once laudable and deplorable. When a hotly‐contested phenomenon like assisted dying is debated, all‐or‐nothing positions tend to be advanced, with little thought given to the desirability of, or prospects for, compromise. In response to recent articles by Søren Holm and Alex Mullock, in this article I argue that principled compromise can be encouraged even in relation to this phenomenon, provided that certain conditions are present (which I suggest they are). In order to qualify as appropriately principled, the ensuing negotiations require disputants to observe three constraints: they should be suitably reflective, reliable and respectful in their dealings with one another. The product that will result from such a process will also need to split the difference between the warring parties. In assisted dying, I argue that a reduced offence of ‘compassionate killing’ can achieve this. I acknowledge, however, that splitting the difference can induce splitting headaches, as there remain certain questions to be answered. Hopefully, however, sufficient work is done here to defend attempts to occupy the middle ground, whether these relate to assisted dying specifically or to other disputed moral matters.     

Assisted Dying & Disability

This article explores at least two dominant critiques of assisted dying from a disability rights perspective. In spite of these critiques, I conclude that assisted dying ought to be permissible. I arrive at the conclusion that if we respect and value people with disabilities, we ought to permit assisted dying. I do so in the following manner. First, I examine recent changes in legislation that have occurred since the Royal Society of Canada Expert Panel on End‐of‐Life Decision‐Making report, published in this journal. I suggest that these changes are likely to only strengthen opposition to assisted dying from disability rights activists and people with disabilities. Second, I focus on respect for people with disabilities and in particular, respect for their autonomy and decision‐making abilities. Third, I explore the opposition to assisted dying that focuses on risk and the vulnerability of people with disabilities. Here I suggest that this risk ought not to be of special concern. Ultimately, I conclude that upholding respect for the disabled requires the legalization of assisted dying, rather than the denial of access in a misguided effort to protect people with disabilities.     

Pharmacokinetics of Sublingual Versus Oral Estradiol in Transgender Women

ObjectiveTo investigate the pharmacokinetics of 17β-estradiol (E2) administered orally versus those of 17β-E2 administered sublingually in transgender women.MethodsSingle doses of 17β-E2 were administered orally (1 mg) to 10 transgender women and then sublingually (1 mg) after a 1-week washout period. Blood samples were collected at baseline (0 hour) and at 1, 2, 3, 4, 6, and 8 hours after dosing. The samples were frozen and analyzed using liquid chromatography mass spectrometry (LC-MS/MS) and immunoassay.ResultsThe results demonstrated that sublingual E2 had a significantly higher peak serum E2 concentration of 144 pg/mL, measured using LC-MS/MS, compared with an oral E2 concentration of 35 pg/mL, measured using LC-MS/MS (P = .003). Sublingual E2 peaked at 1 hour and oral E2 peaked at 8 hours, as measured using LC-MS/MS. The area under the curve (AUC) (0-8 hours) for sublingual E2, measured using LC-MS/MS, was 1.8-fold higher than the AUC (0-8 hours) for oral E2, measured using LC-MS/MS. Additionally, sublingual E2 was found to have an increased E2-to-estrone ratio at all time points (1.1 ± 1.0 vs 0.7 ± 0.4, P ≤ .0001), the clinical significance of which is unclear.ConclusionOral E2 administered sublingually has a different pharmacokinetic profile, with higher serum E2 levels and AUC (0-8 hours) than traditionally administered oral E2. Multidaily dosing may be necessary to suppress testosterone levels with sublingual E2. The appropriate dosing, efficacy, and safety of sublingual E2, compared with those of other E2 preparations, are unknown.     

腹腔镜辅助下阴式子宫切除术与阴式子宫全切除术治疗子宫良性病变的临床比较

目的:探究阴式子宫全切除术与腹腔镜辅助下阴式子宫切除术治疗子宫良性病变的临床效果。方法:选择2011年10月~2013年9月我院收治的子宫良性病变的患者120例,其中行腹腔镜辅助下阴式子宫切除术80例(研究组)和行阴式子全宫切除术40例(对照组),观察并分析两组的临床指标及手术并发症。结果:研究组住院费用明显高于对照组(P0.05),手术时间、术中出血量及住院时间均低于对照组(P0.05);研究组无邻近脏器损伤,对照组输尿管损伤2例(5.00%),研究组患者出现手术损伤率明显低于对照组,差异存在统计学差异(x2=3.968,P=0.046);对两组患者术后随访1年,两组患者均无出现再手术情况;两组患者术后阴道残端均愈合较好,未出现阴道残端漏,患者无大小便困难及其他不适。结论:腹腔镜辅助下阴式子宫切除术治疗子宫良性病变疗效优于阴式子宫全切术,其手术时间、术中出血量及住院时间均较低,创伤小,更有利于患者恢复健康,在临床上值得应用推广。     

Characterization of gene expression profiles in early bovine pregnancy using a custom cDNA microarray

Gene expression analysis comparing nonpregnant with pregnant bovine uteri, including placenta, was performed with a custom cDNA microarray containing 1,933 independent genes. These genes were classified into six categories according to biological function, as follows: cell and tissue structural dynamics (108 genes), intercellular communication (221), intracellular metabolism (265), cell cycle and apoptosis (26), regulation of gene expression (113), expressed sequence tag (EST) and function unknown (617), and uncomplemented genes (583 clones). This array possessed bovine placental/endometrial specificity, as it included many pregnancy-specific molecules, such as pregnancy-associated glycoprotein-1 (PAGs), placental lactogen (PLs), and prolactin-related protein-1 (PRPs). A total of 77 genes were induced and 12 repressed in the placenta/endometrium. Our results point to a fundamental role for bovine placental-specific genes such as PAGs, PLs, and PRPs, in implantation and placentogenesis, and document that cDNA microarray analysis from bovine placenta/endometrium is possible and is a specific tool for monitoring genome-wide gene expression during the establishment and maintenance of pregnancy.     

塔拉豆荚壳中单宁的提取-微波辅助萃取法

利用微波辅助萃取技术对塔拉单宁进行提取,通过不同的起始温度、加蒸馏水量、提取次数、功率大小等实验并用1%的FeCl3溶液检测提取效果,确定较佳的提取温度、次数、加蒸馏水量和微波辅助萃取仪的功率等因素。结果表明,微波提取塔拉单宁的最佳提取条件为:每次提取加水150~200 mL,微波功率400 w,60℃提取20 min,反复提取4次;再升温至70℃提取20 min 2次,即可提取完全。原料中的单宁含量微波浸提比水浴锅浸提稍高。因此认为用此提取方法可替代水浴浸提法。     

Fate of hamster oviductin in the oviduct and uterus during early gestation

Oviductins are a family of glycoproteins which are synthesized and secreted by oviductal secretory cells and which, upon their secretion in the lumen of the oviduct, become associated with postovulatory oocytes and developing embryos. Recently, we showed that hamster oviductin is maximally secreted in the oviduct at the time of ovulation and is later associated with a certain population of uterine epithelial cells, where it is subsequently endocytosed and degraded. In light of these results, this study was conducted to follow the fate of hamster oviductin in the oviduct and uterus during early gestation. Using a monoclonal antibody against hamster oviductin, immunofluorescence and immunogold labeling revealed that during early gestation, immunoreactivity to oviductin in the uterus gradually diminished to an almost total disappearance at time of implantation. However, the strong labeling intensity remained unchanged in the oviduct. Biochemical analyses demonstrated that a degradation of oviductin occurs in the uterus, and a loss of immunoreactivity was also observed as gestation progressed, so that by the time of implantation, immunoreactivity to oviductin was barely detectable. The decrease of oviductin along the uterine epithelium at the time of blastocyst attachment and its final disappearance at implantation suggest that this glycoprotein could be a potential modulator of uterine receptivity. Mol. Reprod. Dev. 46:306–317, 1997. © 1997 Wiley-Liss, Inc.     

Differential Endocrine and Metabolic Effects of Testosterone Suppressive Agents in Transgender Women

Objective: Suppression of testosterone secretion and/or action in transgender women using cyproterone acetate (CPA), spironolactone, or gonadotropin-releasing hormone analogues (GA) is achieved through various mechanisms. Our objective was to characterize possible differential effects of these compounds on metabolic and endocrine variables.Methods: We conducted a historic cohort study of transgender patients treated in a tertiary referral center. A longitudinal analysis of treatment naïve patients and a cross-sectional analysis of the whole cohort at the last visit was carried out.Results: Among 126 transgender women (75 treatment-naïve), CPA was the predominant androgen suppressive therapy (70%), followed by spironolactone (17.6%), and GA (10.2%). Among those who were treatment-naïve, the increase in serum prolactin levels over baseline was greater at 3 months following CPA initiation (mean change 397 ± 335 mIU/L) than following spironolactone (20.1 ± 87 mIU/L) or GA initiation (64.6 ± 268 mIU/L; P = .0002). Prolactin levels remained higher in the CPA-treated group throughout follow-up, irrespective of estradiol levels, which were similar between the groups. A worse metabolic profile was associated with treatment with CPA than with spironolactone or GA. In the CPA compared to the spironolactone and GA groups, high-density lipoprotein-cholesterol levels were lower (47.1 ± 10.4, 54.4 ± 12.2, and 60.3 ± 13, respectively; P = .0076), while body mass index levels (24.3 ± 5, 21.7 ± 2.3, and 20.7 ± 3.1 kg/m²; P = .03), and systolic (117 ± 12.1, 109 ± 12.2, and 105 ± 13.3 mm Hg; P = .01) and diastolic (74 ± 9, 65.6 ± 5.5, and 65.4 ± 11 mm Hg; P = .0008) blood pressure levels were higher at the last visit.Conclusion: Treatment of transgender women with CPA was associated with hyperprolactinemia and a worse cardiovascular risk profile than treatment with spironolactone or GA.Abbreviations: BMI = body mass index; CPA = cyproterone acetate; E2 = estradiol; FSH = follicle-stimulating hormone; GA = gonadotropin-releasing hormone analogues; LH = luteinizing hormone     

Prolactin Levels Do Not Rise Among Transgender Women Treated With Estradiol and Spironolactone

Objective: Existing transgender treatment guidelines suggest that there is a need to monitor prolactin levels in patients receiving transfeminine hormone treatment. Also, recent studies suggest that use of cyproterone acetate as an adjunctive anti-androgen during transgender hormone treatment may elevate serum prolactin. We sought to determine whether the reported relationship between transfeminine estradiol treatment and hyperprolactinemia would be evident when the regimen used spironolactone as the adjunctive anti-androgen.Methods: Estradiol levels, testosterone levels, prolactin levels, body mass index (BMI), and prescribed spironolactone dosage were extracted from the electronic medical records of 98 de-identified transgender women treated with estrogen therapy at the Endocrinology Clinic at Boston Medical Center (BMC). Up to 6 years of data were available for some patients.Results: We found no statistically significant relationship between prolactin and any of the other measures. No estrogen dose-associated elevations in prolactin were found. None of the patients were diagnosed with prolactinoma.Conclusion: Our data suggest that there may be no significant rise in prolactin when transgender women are treated with estrogen along with spironolactone as the adjunct anti-androgen. It may be unnecessary to monitor prolactin in patients on this treatment combination.Abbreviations: BMI = body mass index; BMC = Boston Medical Center; HT = hormone therapy     

Pregnancy Loss Following Coxsackievirus B3 Infection in Mice during Early Gestation Due toHigh Expression of Coxsackievirus-Adenovirus Receptor (CAR) in Uterus and Embryo

Coxsackieviruses are important pathogens in children and the outcomes of neonatal infection can be serious or fatal. However, the outcomes of coxsackievirus infection during early gestation are not well defined. In this study, we examined the possibility of vertical transmission of coxsackievirus B3 (CVB3) and the effects of CVB3 infection on early pregnancy of ICR mice. We found that the coxsackievirus and adenovirus receptor (CAR) was highly expressed not only in embryos but also in the uterus of ICR mice. CVB3 replicated in the uterus 1 to 7 days post-infection (dpi), with the highest titer at 3 dpi. The pregnancy loss rate in mice infected with CVB3 during early gestation was 38.3%, compared to 4.7% and 2.7% in mock-infected and UV-inactivated-CVB3 infected pregnant mice, respectively. These data suggest that the uterus and embryo, which express abundant CAR, are important targets of CVB3 and that the vertical transmission of CVB3 during early gestation induces pregnancy loss.     

Assisted Reproduction and Distributive Justice

The Canadian province of Quebec recently amended its Health Insurance Act to cover the costs of In Vitro Fertilization (IVF). The province of Ontario recently de‐insured IVF. Both provinces cited cost‐effectiveness as their grounds, but the question as to whether a public health insurance system ought to cover IVF raises the deeper question of how we should understand reproduction at the social level, and whether its costs should be a matter of individual or collective responsibility. In this article I examine three strategies for justifying collective provisions in a liberal society and assess whether public reproductive assistance can be defended on any of these accounts. I begin by considering, and rejecting, rights‐based and needs‐based approaches. I go on to argue that instead we ought to address assisted reproduction from the perspective of the contractarian insurance‐based model for public health coverage, according to which we select items for inclusion based on their unpredictability in nature and cost. I argue that infertility qualifies as an unpredictable incident against which rational agents would choose to insure under ideal conditions and that assisted reproduction is thereby a matter of collective responsibility, but only in cases of medical necessity or inability to pay. The policy I endorse by appeal to this approach is a means‐tested system of coverage resembling neither Ontario nor Quebec's, and I conclude that it constitutes a promising alternative worthy of serious consideration by bioethicists, political philosophers, and policy‐makers alike.     

Assisted Suicide in Switzerland: Clarifying Liberties and Claims

Assisting suicide is legal in Switzerland if it is offered without selfish motive to a person with decision‐making capacity. Although the ‘Swiss model’ for suicide assistance has been extensively described in the literature, the formally and informally protected liberties and claims of assistors and recipients of suicide assistance in Switzerland are incompletely captured in the literature. In this article, we describe the package of rights involved in the ‘Swiss model’ using the framework of Hohfeldian rights as modified by Wenar. After outlining this framework, we dissect the rights involved in suicide assistance in Switzerland, and compare it with the situation in England and Germany. Based on this approach, we conclude that in Switzerland, claim rights exist for those requesting suicide assistance, and for those who are considering providing such assistance, even though no entitlements exist toward suicide assistance. We then describe the implementation of the ‘Swiss model’ and difficulties arising within it. Clarifying these issues is important to understand the Swiss situation, to evaluate what features of it may or may not be worth correcting or emulating, and to understand how it can impact requests for suicide assistance in other countries due to ‘suicide tourism’. It is also important to understand exactly what sets Switzerland apart from other countries with different legislations regarding suicide assistance.     

Potassium Concentrations in Transgender Women Using Spironolactone: A Retrospective Chart Review

ObjectiveTo assess the incidence of hyperkalemia in transgender women using spironolactone.MethodsThis was a retrospective chart review of transgender women who received gender-affirming hormone therapy that included spironolactone between January 2000 and September 2018. Forty-four participants who had paired potassium concentrations documented and were on spironolactone were included and analyzed. Study outcomes included the incidence of hyperkalemia (serum potassium concentrations > 5.0 mmol/L), the relationship between the duration of treatment and degree of hyperkalemia, and difference between serum potassium concentrations at the beginning of spironolactone treatment versus last serum potassium concentrations.ResultsThe median age of the participants was 36.5 years. The cohort was predominantly non-Hispanic White (32/44). No serum potassium concentration was >5.5 mmol/L, and all participants had serum creatinine level of <2 mg/dL. Median duration of treatment was 25 months (range 2-92 months) and 140 potassium measurements were available. The mean potassium concentration (3.87 mmol/L) before the initiation of spironolactone was lower than the mean potassium concentration (4.03 mmol/L) while on spironolactone (mean difference, 0.16 mmol/L, P = .013). The regression β, that is, the average change in potassium concentration per 1 additional month of treatment duration, was ?.001 (95% CI [?.004, .001]; P = .255) signifying no relation between treatment duration and spironolactone use.ConclusionNo participant had laboratory evidence of significant hyperkalemia (K > 5.5 mmol/L) after initiation of spironolactone. Frequent measurement of potassium concentrations might be unnecessary in transgender women taking spironolactone in patients with serum creatinine levels of <2 mg/dL.     

Sex Partnership and Self-Efficacy Influence Depression in Chinese Transgender Women: A Cross-Sectional Study

Background

Transgender women often suffer from transition-related discrimination and loss of social support due to their gender transition, which may pose considerable psychological challenges and may lead to a high prevalence of depression in this population. Increased self-efficacy may combat the adverse effects of gender transition on depression. However, few available studies have investigated the protective effect of self-efficacy on depression among transgender women, and there is a scarcity of research describing the mental health of Chinese transgender women. This study aims to describe the prevalence of depression among Chinese transgender women and to explore the associated factors.

Methods

A cross-sectional study was conducted in Shenyang, Liaoning Province of China by convenience sampling from January 2014 to July 2014. Two hundred and nine Chinese transgender women were interviewed face-to-face with questionnaires that covered topics including the Zung Self-Rating Depression Scale (SDS), demographic characteristics, transition status, sex partnership, perceived transgender-related discrimination, the Multidimensional Scale of Perceived Social Support (MSPSS) and the adapted General Self-efficacy Scale (GSES). A hierarchical multiple regression analysis was performed to explore the factors associated with SDS scores.

Results

The prevalence of depression among transgender women was 45.35%. Transgender women with regular partners or casual partners exhibited higher SDS scores than those without regular partners or casual partners. Regression analyses showed that sex partnership explained most (16.6%) of the total variance in depression scores. Self-efficacy was negatively associated with depression.

Conclusions

Chinese transgender women experienced high levels of depression. Depression was best predicted by whether transgender women had a regular partner or a casual partner rather than transgender-related discrimination and transition status. Moreover, self-efficacy had positive effects on attenuating depression due to gender transition. Therefore, interventions should focus on improving the sense of self-efficacy among these women to enable them to cope with depression and to determine risky sex partnership characteristics, especially for regular and casual partners.     

On the Moral Acceptability of Physician‐Assisted Dying for Non‐Autonomous Psychiatric Patients

Several authors have recently suggested that the suffering caused by mental illness could provide moral grounds for physician‐assisted dying. Yet they typically require that psychiatric‐assisted dying could come to question in the cases of autonomous, or rational, psychiatric patients only. Given that also non‐autonomous psychiatric patients can sometimes suffer unbearably, this limitation appears questionable. In this article, I maintain that restricting psychiatric‐assisted dying to autonomous, or rational, psychiatric patients would not be compatible with endorsing certain end‐of‐life practices commonly accepted in current medical ethics and law, practices often referred to as ‘passive euthanasia’.