Frontiers in Global Women’s Health 7 February 2022, Volume 3
by Karleen D Gribble, Susan Bewley, Melissa C Bartick, Roger Mathisen, Shawn Walker, Jenny Gamble, Nils J Bergman, Arun Gupta, Jennifer J Hocking, Hannah G Dahlen
Introduction
On 24 September 2021, The Lancet medical journal highlighted an article on its cover with a single sentence in large text; “Historically, the anatomy and physiology of bodies with vaginas have been neglected.” This statement, in which the word “women” was replaced with the phrase “bodies with vaginas,” is part of a trend to remove sexed terms such as “women” and “mothers” from discussions of female reproduction. The good and important intention behind these changes is sensitivity to, and acknowledgment of, the needs of people who are biologically female and yet do not consider themselves to be women because of their gender identity. However, these changes are often not deliberated regarding their impact on accuracy or potential for other unintended consequences. In this paper we present some background to this issue, describe various observed impacts, consider a number of potentially deleterious consequences, and suggest a way forward.
Sex (a reproductive category), gender (a societal role), and gender identity (an inner sense of self) are not synonymous. Sex is salient to reproduction, as there are only two gametes and pubertal pathways to adulthood and gamete production, and only one gamete producing body type that becomes pregnant. As a general principle of communication it is well established that the sex of individuals should be made visible when it is relevant and should not be invoked when it is not). This facilitates avoidance of sex stereotyping while ensuring that sex-based needs and issues are not overlooked. In communication related to female reproduction, sexed language including the words “women” and “mothers” has therefore predominated. Yet, this usage has been challenged in response to rising numbers and visibility of people who have a gender identity which means they do not wish to be referred to as such). As described below, we should address individuals as they wish, but more broadly there are risks to desexing language when describing female reproduction.
The discussion here is presented with an explicitly global audience in mind. While people who do not conform to the social expectations of their sex are ubiquitous throughout the world, the response to such individuals is influenced by culture in which they reside. This includes in the level of acceptance or marginalization they experience, the ways in which they are accommodated and the ways in which their non-conformity is conceptualized. It should be recognized that the penalty for non-conformity with gender roles can be high. Where the concept of gender identity is salient, desexing the language of female reproduction has emerged as an accommodation to remedy marginalization. However, it needs to be kept in mind that pregnant and birthing women and new mothers and their infants have unique vulnerabilities and also require protection.
Each day, an estimated 810 women die during pregnancy, birth, and afterwards, with the majority of deaths in low- and middle-income countries. More women across low-, middle- and high-income countries suffer life threatening pregnancy and birth complications with short- and long-term consequences. Maltreatment and obstetric violence occurs everywhere and significantly contributes to birth trauma. Puerperal psychosis affects 1–2 in every 1,000 mothers often in the first few days after birth and is a leading cause of maternal death through suicide, as well as infanticide. Maternal deaths from non-medical causes such as suicide and injury, are gaining increased attention from leading health bodies such as the World Health Organization, with calls to extend reporting to a year after birth. Globally, 3.9 million infants die each year. Over 800 000 of these deaths are attributable to premature cessation of exclusive or any breastfeeding. Even in the wealthiest contexts, early discontinuation of breastfeeding is responsible for a large proportion of infant hospitalisations. Thus, Article 25 of the Universal Declaration of Human Rights says that the states of “motherhood and childhood are entitled to special care and assistance” and the United Nations Convention on the Rights of the Child states that the best interests of the child are paramount.