Uterus transplantation is a recent addition to techniques assisting childless people in the pursuit of biological children. A research team lead by Professor Brännström at Sahlgrenska University Hospital in Sweden made history in September 2014 with the birth of the world’s first baby born after uterus transplantation. The birth was part of experimental procedures of temporary uterus transplants, aiming at one or two births followed by hysterectomy because of the infection risk and the need of immunosuppression to avoid rejection of the transplanted organ (Brännström et al 2015, 2018). Experimental transplant trials with live or deceased uterus donors are already performed worldwide (Guntram and Williams 2018b). Live births have been reported from Europe, North America, Latin America, and Asia (Brännström et al 2019).

This article investigates twenty years of discursive struggles in Nordic medical journals around the process of legitimating and routinising uterus transplantation in Sweden, on the one hand, and gestational surrogacy in Finland, on the other, through critical discourse analysis of a solid corpus of Finnish and Swedish medical journal texts from 1/1/2000 to 31/12/2019. The aim is to explore tensions between routinisation and resistance by analysing central discursive turning points in the medical journal discussions and reflecting them against medical and public policy developments during the analysed twenty-year period. Hence, the article investigates the role of health care professionals in the partially intertwined development of these two reproductive practices in these neighbouring countries over two decades, considering differences in the countries’ regulatory approaches to biotechnology and assisted reproductive technologies (ART). A comparative approach to surrogacy and uterus transplantation is fruitful, as it addresses parallel and interlinked medical discourses on reproductive donation, infertility, and conditions of the uterus.

While many ARTs already are routinised and taken for granted as normalised and naturalised means of reproduction (Franklin 2013; Lie and Lykke 2016), these two methods involving biomedicalisation of human reproduction and the gendered body (Clarke et al 2003, 2010; Riska 2010) are still relatively contested. Uterus transplants are not yet a routinised means of reproduction, being experimental procedures, which are not yet part of public reproduction and biotechnology policies. Commercial surrogacy is legal in quite few countries, many of which are in the Global South or Global East, and most nations have banned or greatly restricted gestational surrogacy (Schurr 2018). Hence, despite its relatively long history, surrogacy is still considered controversial in most parts of the world, being associated with legal and ethical uncertainties and risks. While Sweden is a pioneer in uterus transplants, Finland introduced unpaid gestational surrogacy on a limited scale on medical grounds relatively early, in 1991, and Finland is still the only Nordic country that has practised gestational surrogacy in domestic health care. However, since the enactment of the Finnish Act on Assisted Fertility Treatments (1237/2006) in 2007, surrogacy arrangements are longer permitted in Finnish health care (Eriksson 2016).

Swedish legislation does not allow gestational surrogacy to be conducted in Swedish health care (Kroløkke and Nebeling Petersen 2017, p. 208; Gunnarsson Payne 2018). Surrogacy is in other respects mostly unregulated in Sweden, contributing to long processing times in determination of legal parenthood in cross-border surrogacy (Gunnarsson Payne and Handelsman-Nielsen 2022). Since 2010, a growing number of Swedes have travel abroad for commercial surrogacy arrangements (SOU 2016:11, pp. 456–458). As a contested issue, surrogacy has been found to be more widely debated than uterus transplants in Swedish media (Kroløkke and Petersen 2017, p. 194). Swedish public debates on surrogacy have been characterised by polarisation between anti-surrogacy feminist discourse on the exploitation of women and pro-surrogacy discourse on the role of legislation banning exploitative surrogacy practices and facilitating good practices of surrogacy, often emphasising LGBTQ parenting (Gondouin 2012; Arvidsson et al 2015).

Like other publicly funded health care systems, Finland and Sweden will eventually have to decide whether to publicly finance uterus transplants, presupposing that uterus transplants will prove to be effective, safe, and cost-effective. One of the common arguments against public funding of uterus transplantation is the availability of alternatives such as adoption and surrogacy, but adoption does not enable a genetic link, and thus surrogacy and uterus transplantation are more comparable, especially when practised within domestic health care (Wilkinson and Williams 2016). On the one hand, uterus transplantation is often positioned in ethics and science literature as a morally less problematic alternative to surrogacy (Guntram and Williams 2018b). On the other hand, gestational surrogacy is a low-tech option in comparison with the medically advanced procedure of uterus transplantation, requiring complicated surgeries followed by high-risk pregnancies (Kroløkke and Petersen 2017).

Theoretically, I draw from the concepts of biomedicalisation (Clarke et al 2003, 2010) and bio-intimacy (Kroløkke and Petersen 2017), i.e. the relational dynamics between donors and recipients (Beier and Wöhlke, 2019), which is often based on kinship or other close relationships in the Nordic context (Kroløkke and Petersen 2017). The article presents the relatively unexplored and rare phenomenon of gestational surrogacy arrangements between close relatives or close acquaintances, which is central to the legitimation of surrogacy in Finland (Söderström-Anttila et al 2002; Eriksson 2022). I analyse how uterus transplantation and gestational surrogacy are represented as reproductive technologies involving uterine exchanges (Kroløkke and Petersen 2017), in which kinship between donors and recipients is either a medical advantage or might involve social and emotional risks (Guntram and Williams 2018b). Gestational surrogacy and uterus transplantation reinforce genetic aspects of reproduction and motherhood through emphasis on the uterus as reproductive instrument for achieving a child genetically linked to one or two parents (Kroløkke and Petersen 2017). Thus, despite changing the ways we make babies, gestational surrogacy and uterus transplantation reinforce hegemonic family and kinship norms by imitating biological processes of reproduction (Franklin 2013).

Previous research has found that surrogacy was through medicalisation discursively framed in the Parliament of Finland in the early 2000s as an infertility treatment for women with a missing or malfunctioning uterus (Eriksson 2016; 2022). This article explores how this discursive framing came about in Finnish medical discourse, and how uterus transplants in contrast was introduced in Swedish medical discourse as the preferable infertility treatment. The discourse analytical approach can contribute to increased reflexivity about biomedical claims-making by interpreting its importance for the establishment of biotechnologies through framings of evidence-based knowledge, and its impact on routinisation through policy developments. The study also contributes to expose medical discourse about uterus transplantation in the Swedish and Nordic context where it pioneered.

The article is structured as follows: The following sections explain the theoretical framework, method, and materials. The analytical sections are partially chronologically and comparatively structured by identifying central discursive turning points in the medical journal discussions. The first analytical section analyses legitimation of surrogacy law by Finnish authors, while the second analyses how surrogacy and uterus transplantation were legitimated by Swedish authors. Medical discourse is interpreted against the background of broader public policy developments in relation to surrogacy, and their implications for uterus transplantation. Central topics are analysed in detail in the final analytical sections based on authors’ arguments in all journals: absolute uterine factor infertility and its treatments, bio-intimacy in reproductive donation, and representations of uterus transplantation as an innovation. Finally, I conclude by summarising findings and developing comparative conclusions.

Biomedicalisation of human reproduction and the gendered body

Physicians are central actors in the reproductive field because of their professional authority and social status. The medical community has a particularly strong impact on state regulation of ART in countries, where new applications of ART and biotechnologies are self-regulated by the medical community. The ability to influence state policies is stronger if ART physicians are largely in agreement, for example on policies developed by medical associations. Both Finland and Sweden have developed permissive ART policies, which grant the medical community broad autonomy and provide treatment access regardless of civil status or sexual orientation (Engeli and Rothmayr Allison 2016, pp. 90–93).

Medicalisation refers to aspects of life being constructed as medical problems (Clarke et al 2003). Several authors have argued that women’s lives and bodies have been disproportionately medicalised, particularly in relation to reproduction and childbirth (Riessman 1983; Riska 2010). Through medicalisation, healthcare professionals act as gatekeepers, determining access to reproductive technologies, often according to hegemonic parenthood norms. Medicalisation may thus contribute to structural inaccessibility in health practices and policies and to treatment disparities of infertility by perpetuating the stratified system of reproduction, and creating institutional barriers, for example, for women of low socio-economic status (Bell 2010). However, medicalisation is also a contested concept as it overemphasises medicine’s dominance while underplaying its benefits (Rose 2007a; Busfield 2017). Rose argues that medicine’s impact goes beyond medicalisation, because it “has made us into what we are” through medical practices, medical meaning, and medical authority: “Medicine is inextricably intertwined with the ways in which we experience and give meaning to our world” (Rose 2007a, p. 701).

The concept of biomedicalisation (Clarke et al 2003, 2010; Riska 2010) was developed as a critique of the concept of medicalisation. Clarke and her colleagues describe biomedicalisation as encompassing intensified, multisited, and multidirectional processes of medicalisation, and social changes relating to technoscientific biomedical innovations and their commercialisation, which have far-reaching consequences for perceptions of health, risk, surveillance, and the human body (Clarke et al 2003). Among the processes included in biomedicalisation, the three most relevant for this article are as follows: (1) the increasing technoscientific nature of biomedical innovations, (2) transformations of biomedical knowledge production and consumption, and (3) the transformations of bodies in relation to new technoscientific identities through the development of customised and individualised drugs and technologies (Clarke et al 2003, 2010). As an example of the third process, the biomedicalisation of reproduction and infertility includes identifying women as potential patients and developing treatments that fit the category infertile, thereby disregarding ambiguity in women’s perceived fertility or infertility (Greil and McQuillan 2010).

Throughout the analysis, I investigate how processes of biomedicalisation emerge and reconfigure in the material as part of the routinisation of reproductive technologies alongside other factors, particularly the relational dynamics of reproductive donation, which will be discussed in the next section.

Routinisation and the relational dynamics of surrogacy and uterus transplantation

Through reproductive donation, such as surrogacy and uterus donation, kinship is marked in new ways, which exceeds the boundaries between biological and social kinship (Kroløkke et al 2016, pp. 1–5). Rose (2007b, pp. 17–18) argues that reproductive technologies and organ transplantation are “technologies of life”, which reshape the future by changing what it is to be biological human beings and by creating new social relations between donors and recipients. In my analysis of medical journal discussions, I will explore how these social relations between reproductive donors and recipients are described in relation to surrogacy and uterus transplantation, and how the relational dynamics is discursively framed as essential for the legitimation of the methods.

Previous research has found that the competing framings of surrogacy as exploitation/inequality and opportunity/choice are central in narratives about surrogacy as motivated by either coercion or a wish to help (Markens 2012; Rudrappa and Collins 2014). Recent ethnographic scholarship on surrogacy and reproductive donation has challenged the dichotomous frames of altruism and commodification, understanding them rather as embodied biolabour (Pande 2020) or clinical labour (Cooper and Waldby 2014). In a comparative study of surrogacy and uterus transplantation, Kroløkke and Petersen (2017) conceptualise the two methods as uterine exchanges, in which the uterus receives “bio-intimate (re)productive value” (Kroløkke and Petersen 2017, p. 192). They argue that surrogacy and uterus transplantation “become ethically legitimate forms of assistance by being embedded in already organised structures of intimacy (the heterosexual family and kinship)” (Kroløkke and Petersen 2017, p. 207). Through my analysis, I will develop the concept of bio-intimacy in reproductive donation by analysing arguments about ambivalent bio-intimacy between donors and recipients based on kinship or close relationships. In a comparative study of surrogacy and living kidney donation within close relationships, Beier and Wöhlke (2019) found that the relational dynamics between donors and recipients—or surrogates and intended parents in the case of surrogacy—has often been underestimated, both when surrogacy arrangements occur between strangers and in familial relationships. Live kidney donation usually occurs in close relationships. The authors argue that this complex relational dynamics in both practices included challenges of unresolved reciprocity, gender stereotypes, and social norms of altruism in contrast to the cultural rule that gifts are never unconditional (Beier and Wöhlke 2019).

Routinisation is another central concept in this article, which analyses the process of legitimating and routinising surrogacy and uterus transplantation. Routinisation involves cultural, legal, and socio-economic adaptions of a biotechnology or procedure (Wahlberg 2016). Thompson (2005, pp. 79–81) argues that bureaucratic routinisation is part of techniques of normalisation, by which new scientific knowledge and medical procedures are incorporated into pre-existing procedures. She has explored the ontological choreography of ART clinics, including the dynamics of how technologies, kinship and gender norms, and political and financial matters are intertwined, thereby contributing to ARTs being routinised in a society. Whereas normalisation of ARTs at the level of individual experience refers to ARTs becoming an embodied way of life (Franklin 1997), and part of techniques of normalisation, including, for example, marriage, kinship, consumer culture, and biomedicine, ARTs become routinised at the societal level by being associated with social and institutional norms and established through policies and regulations (Franklin 2013). I would add that biomedicalisation through biomedical knowledge production—such as the analysed medical journal discussions—has an essential role for the routinisation of ARTs.

According to Wahlberg (2016), a common route of routinisation of experimental biotechnologies is a continuum from pioneering innovations, followed by concerns and resistance, and finally regulation and increased availability of the technology, making it accepted or mundane. For example, Wahlberg (2016) argues that ARTs were routinised in China by being transformed from pioneering into mundane, simultaneously being incorporated into China’s restrictive family planning policies. However, Wahlberg’s description of gradual liberalisation diminishes the role of resistance and restrictions, which in the case of surrogacy are recurring. Cultural adaptation of ART in relation to cultural and religious norms on family and kinship often involves clashes of values (Eriksson 2019). As noted by Lie and Lykke (2016, p. 17), ARTs are still in many countries restricted by state regulations and perceived as controversial in relation to cultural and religious belief systems.

The legal landscape of the global surrogacy market is currently characterised by rapid changes and the development of new surrogacy destinations and new markets (Whittaker 2018). This fluidity of the global surrogacy market indicates a relatively low level of routinisation globally. For example, commercial surrogacy was banned for gay couples and single intended parents in India in 2012, followed by legislative bans on commercial surrogacy for foreign nationals in Thailand, Nepal, and India in 2015, and in Cambodia in 2016. These bans have triggered new reprohubs marketing commercial surrogacy, for example in Laos, Ghana, and Kenya (Whittaker 2018, pp. 170–171). Despite the low level of routinisation of gestational surrogacy and uterus transplants globally, they can become more routine and mundane at a national level by being incorporated into existing procedures and associated with the already routinised technique of IVF (cf. Thompson 2005, pp. 79–81; Franklin 2013, p. 6).

The primary empirical material was collected from four Nordic medical journals: the two Finnish journals Suomen Lääkärilehti (SLL) and Duodecim, the Swedish journal Läkartidningen, and the Nordic journal Acta Obstetricia et Gynecologica Scandinavica (AOGS) from 1/1/2000 to 31/12/2019. This period of twenty years was chosen based on relevance of articles in the selected journals. The number of articles on surrogacy has increased in the journals since 2000. Most analysed articles on uterus transplantation are published after 2010, due to its short history. Intertextuality and interdiscursivity are analysed through secondary material of newspaper articles and governmental reports.

SLL is the leading medical journal in Finland, published by The Finnish Medical Association, of which almost all physicians in Finland are members (Lääkärilehti 2024). Duodecim is published by The Finnish Medical Society Duodecim (Duodecim 2024). Both journals are targeted at health care professionals and students in Finland. Läkartidningen is the leading medical journal in Sweden, published by The Swedish Medical Association (Läkartidningen 2024). AOGS is published by The Nordic Federation of Societies of Obstetrics and Gynecology (NFOG 2024). It differs from the others by publishing in English and focusing specifically on reproduction, obstetrics, and gynaecology.

The material was collected through journal archive and database searches on search words “sijaissynnytys”, “surrogatmoderskap”, “surrogatmödraskap” (surrogacy); and “kohdunsiirto”, “livmodertransplantation” (uterus transplantation) in the Finnish and Swedish journals, as well as “surrogacy”, “uterus transplantation”, and “uterine transplantation” in AOGS. After sorting out duplicates and content-irrelevant search results, the data collection resulted in the analytical sample of 97 articles: 14 in SLL, 7 in Duodecim, 43 in Läkartidningen, and 33 in AOGS. Differences in the extent of material is due partially to frequent debate articles in Läkartidningen. The journals have interconnected discourse, because some Finnish authors write in Läkartidningen, and AOGS articles are written by Nordic and international authors. Some articles mention either surrogacy or uterus transplantation, while others compare them. I included all types of texts except book reviews (see Table 1). Only 16 were peer reviewed original articles, but since all texts were published in medical journals, they are part of medical knowledge production. Furthermore, by including commentaries and debate articles also by non-health care professionals, the analytical sample captures both medical discourse and partly also challenges of it.

I used critical discourse analysis (CDA) to explore discourses in the four journals and to structure and map the material. A discourse is here understood as a central line of argumentation, through which ideas and problems are given meaning. CDA aims to discover discursive and social change and to clarify the role of discourses in maintaining unequal power relations. The discourse analyst should constantly alter analytical focus between text, discursive practice, and social practice (Fairclough 1992, pp. 225–226, 231). At the text level, I analysed argumentation, phrasing, and metaphorical language. The word choices indicate which associations authors expect to evoke, for example by presenting claims as evidence-based medical knowledge, thereby concealing any ideological effects. At the level of discursive practice, I analysed formation of discourses by searching for similar meaning constructions and competition between discourses. I studied intertextuality by observing links between text elements in medical journals and in news media. I studied interdiscursivity by observing how authors build on existing discourses, for example prevalent political ones, and how medical discourse resonated in relevant legislative reports. By analysing social practice, I focused on the social context of the text and its political and ideological effects (Fairclough 1992, pp. 232–238). I paid particular attention to discursive turning points in the texts by reflecting them against medical and public policy developments in relation to surrogacy and uterus transplantation and observed how medical discourse highlights some aspects of surrogacy and uterus transplantation and conceals others.

I selected examples from the thematically and discursively most relevant medical articles. Quotations were selected as either representative of the material or critical incidents bringing something different to the text and representing a boundary or interruption (Fairclough 1992, p. 230). Furthermore, I paid particular attention to modality, concerning the degree of agreement or occurrence of truth claims (Fairclough 1992, pp. 158–159), and transitivity, concerning how meaning of events is represented in relation to agency and causality (Fairclough 1992, pp. 177–181). I translated the Finnish and Swedish quotations verbatim. The translation work required reflexivity and sensitivity to how the word order and nuances can change how the text is perceived. However, I am aware that cultural nuances in the symbolic discussion of gender, reproduction, and fertility cannot always be translated.

Legitimation and the promotion of surrogacy law reform in Finland

While surrogacy and other reproductive technologies were unregulated in Finland until 2007, they were self-regulated by clinics, and the medical community defined treatment supply and access (Engeli and Rothmayr Allison 2016, p. 90; Eriksson 2016). Finnish physicians introduced surrogacy arrangements in 1991 by identifying a patient need, and actively advocated the legalisation of surrogacy arrangements to continue operating within the framework of the Act on Assisted Fertility Treatments (1237/2006) that had been under preparation since the 1990s. However, the Act incorporated most of the already established clinical applications of ART with the exceptions of surrogacy and donor anonymity (Eriksson 2016).

The practice of gestational surrogacy at Finnish clinics was developed through biomedicalisation of the reproductive practice and by emphasising kinship or an otherwise established relationship as a resource and condition of access. In summary, treatment access was narrowly defined by the attending healthcare professionals. All intended parents in the surrogacy arrangements were heterosexual couples. Most intended mothers had a non-functional or absent uterus, either from birth (e.g. the Mayer-Rokitansky-Küster-Hauser syndrome, MRKH) or because of a gynaecological disease or childbirth complications. The surrogates were sisters, mothers, cousins, friends, or other volunteers, which had to be recruited by the intended parents (Söderström-Anttila et al 2002, pp. 748–750/AOGS). Hence, a normalising and legitimating discourse in relation to biomedicalisation and close relationships was frequent in articles in the analysed medical journals written by Finnish physicians advocating legalisation of altruistic surrogacy by arguing for inclusion of unpaid altruistic surrogacy in public health services on medical grounds.

The Finnish experience of gestational surrogacy was often represented as a medical success story, measured according to pregnancy rate, number of births, and health of children, surrogates, and intended parents. A key article co-authored by ten physicians who provided surrogacy arrangements at Finnish clinics focused on the success of the arrangements, and on the physical and mental health of surrogates and intended parents: “Altruistic IVF surrogacy works well, but careful counselling of all parties involved is essential” (Söderström-Anttila et al 2002, 747/AOGS). The purpose of counselling was to avoid depression among surrogates and potential disagreements about for example the mode of delivery. A high pregnancy rate because of a well-functioning hormone replacement protocol was mentioned as evidence of medical success of Finnish surrogacy arrangements (Söderström-Anttila et al 2002, 751/AOGS). Another article described Finnish surrogacy arrangements by the truth claim “the best in the world” with reference to the high live birth rate of 59% (Suikkari 2002/SLL).

Finnish physicians have justified the practice of surrogacy in all analysed medical journals (e.g. Hovatta 2000/AOGS; Söderström-Anttila et al 2002/AOGS; Hovatta and Söderström-Anttila 2013/Läkartidningen; Söderström-Anttila in Vehmanen 2013, 647/SLL; Söderström-Anttila 2014/Läkartidningen; Söderström-Anttila and Suikkari 2016/Duodecim). For example, chief physician Hovatta addressed claims about risks and complications in surrogacy arrangements when arguing that surrogacy has been practised in well-prepared cases in Finland:

There has been a fear of unexpected complications as regards the parenthood of the child involved. However, such occurrences have not yet been encountered in cases of IVF surrogacy. The bad reputation of surrogacy came from a completely different case in the United States some years ago (Hovatta 2000, 922/AOGS).

The unexpected and uncertain feature of transnational surrogacy had provided gestational surrogacy a bad reputation, according to Hovatta representing the non-governmental organisation the Family Federation of Finland, whose fertility clinic offered surrogacy arrangements at the time. The surrogate in the above-mentioned court case did not want to give away the child to the intended parents. This claim was interdiscursively connected to Finnish parliamentary debates on surrogacy, in which many Members of Parliament claimed that legalising surrogacy at safe clinics in Finland was better than outsourcing surrogacy to other countries (Eriksson 2022).

A central turning point in both Finnish physicians’ legitimation of surrogacy and in the Finnish law drafting process was when the Finnish Ministry of Justice presented three regulatory options in a memorandum about surrogacy in 2012 (OMSO 2012). Most consultation opinions by Finnish authorities and organisations welcomed limited permission for non-commercial surrogacy on medical grounds, which corresponded to previous clinical practice from 1991 to 2007 (Ministry of Justice 2013). The Ministry of Justice memorandum did not result in a bill. However, the advisors’ comments indicated that unpaid gestational surrogacy on medical grounds still had relatively broad societal support. Hence, this suggests that the Finnish medical community has been influential in the routinisiation process of surrogacy through clinical practice and by advocating legalisation in medical journals as well as in newspapers (e.g. Söderström-Anttila and Suikkari 2013).

In an article titled “Surrogacy should be allowed in Finland”, Söderström-Anttila and Suikkari, representing the Family Federation of Finland fertility clinic, claimed that legislators did not have enough resources to thoroughly inquire into surrogacy before the 2007 Act: “The ban took effect even though infertility of about twenty couples had until then been successfully treated through surrogacy in Finland” (Söderström-Anttila and Suikkari 2016, 1932/Duodecim). The authors represented surrogacy at Finnish clinics with a high modality as successful medical treatments of infertility. In contrast, they described Swedish uterus transplantation trials as risky but successful: “The project was completely experimental and was known to involve significant risks for uterus donors, recipients, and most of all, for children” (Söderström-Anttila and Suikkari 2016, 1933/Duodecim). By referring to “completely experimental” and “significant risks”, they altered the level of modality when discussing uterus transplantation. They concluded: “Could Finnish authorities and politicians be equally bold by granting us permission to carefully perform ten gestational surrogacy treatments in a carefully prepared study?” (Söderström-Anttila and Suikkari 2016, 1933/Duodecim) This proposal applied the experimental nature of uterus transplants to surrogacy, despite it being a much older and widely practised reproductive technology. The proposal was an attempt to circumvent the slow law drafting process of permitting gestational surrogacy, which would be a more relevant option for routinisation, as it has already been practised non-experimentally in Finland and elsewhere. The proposal was quoted by Finnish tabloid press, which provided it broad publicity (e.g. Salonen 2016), but it was never implemented.

Despite the Finnish medical community’s successful biomedicalisation of gestational surrogacy, and a relatively successful discursive impact in the societal debate, surrogacy has to date not been legalised in Finland. An objective of Prime Minister Marin’s Government Programme in 2019 was to examine the possibility for non-commercial surrogacy within Finnish health care. No bill was presented during the government period, but the Ministry of Justice presented a report in 2023. The report proposed limited permission of non-commercial surrogacy by which intended parents could receive treatment for medical or biological reasons, and the surrogate should be a close relative or close acquaintance of the intended parents (Ministry of Justice 2023). Thus, the report built strongly on established clinical practice of surrogacy with the additions, inter alia, that the embryo should have a genetic connection to either intended parent, and that surrogacy should be available for intended parents regardless of marital status or gender, including same-sex couples and those who wish to have a child alone. The latter condition differed from the narrower biomedicalised version of surrogacy arrangements advocated in the analysed medical journals and was motivated in the report by reference to societal equality values.

Successive questioning of surrogacy and introduction of uterus transplantation in Sweden

In the analysed journals, the Swedish medical community has often presented comparisons between surrogacy and uterus transplantation, on the one hand, and comparisons to Finland’s clinical application of surrogacy, on the other. In the following example, the Swedish Professor of Obstetrics and Gynaecology Hamberger expressed in a debate article from 2002 that he preferred surrogacy over uterus transplantation, representing surrogacy as a safer and globally routinised and successful way of producing genetic offspring—mentioning Finland as an example—while uterus transplantation was questioned as a risky procedure:

Many thousands of such pregnancies resulting in healthy children have already been born in different parts of the world, including Finland. Careful psychosocial follow-ups show unequivocally that surrogacy generally works well, especially if the surrogate mother is the infertile woman’s mother or sister. […] The procedure [of uterus transplantation] is thus very complex and associated with substantial risks for both mother and child. In comparison, surrogacy thus seems much easier, much safer, and not least infinitely cheaper than this ‘new-old’ transplantation method (Hamberger 2002, 3870/Läkartidningen).

Expressions such as “healthy children” and “healthy young women” were examples of biomedicalising discourse with high modality through truth claims, representing surrogacy as a successful infertility treatment, and in the above example, emphasising the advantage of a kinship relation between the surrogate and the intended mother, who is called “the infertile woman”. However, already in 2008, the Swedish uterus transplantation pioneers Brännström and Wranning represented surrogacy as an out-dated method in comparison with the new transplantations. However, the authors described uterus transplantation with lower modality as an experimental procedure, as it was not yet successful.

However, this procedure [surrogacy] is not approved by most societies in the world, including the Nordic countries, because of legal, ethical and/or religious reasons. Transplantation of the uterus has been proposed as a fertility treatment for women with absolute uterus infertility who cannot or do not wish to use surrogacy or adoption as a means to form a family and who have a strong desire to carry a pregnancy (Brännström and Wranning 2008, 1097/AOGS).

This quotation was an attempt at cultural, legal, and socio-economic adaptation, which is part of the routinisation process of biotechnologies (Wahlberg 2016). Brännström and Wranning introduced uterus transplantation as a future infertility treatment without the method of surrogacy’s baggage of legal, ethical, and religious conflicts. However, uterus transplantation was met with resistance by other Swedish health care professionals. In the following example, Swedish physicians argued against uterus transplantation by claiming that biotechnology has gone astray:

It seems as if we here have a case, where our moral compass chaotically flutters of innovation zeal and a wish to come (almost) first (Johansson and Sahlin 2011/Läkartidningen).

The authors challenged the discourse of uterus transplantation as an innovation by representing it as a matter of scientific competition. The metaphor of the chaotically fluttering moral compass illustrated bioethical uncertainty. Other Swedish authors questioned the possibility of cultural adaptation of uterus transplantation and suggested that surrogacy should be permitted: “How will religious, social, economic and cultural conditions affect the assessment of the risks?” (Hallén et al 2010, 2903/Läkartidningen).

The number of articles on surrogacy in the Swedish medical journal Läkartidningen peaked between 2010 and 2016 in connection with the publication of a report and a white paper on ART and surrogacy (Smer rapport 2013:1; SOU 2016:11). In the report Assisted reproduction – ethical aspects, the Swedish National Council on Medical Ethics argued that altruistic surrogacy could be ethically acceptable under certain conditions (Smer rapport 2013:1). However, this proposal was met with some hesitance in Läkartidningen, and in the following example by a Swedish physician, surrogacy was associated with ambivalence as a source of risk and uncertainty: “there is no reliable boundary between altruistic and commercial surrogacy” (Kjellmer 2013, 725/Läkartidningen). As noted by Franklin (2013, pp. 7–9), technological ambivalence is profoundly associated with ART by representing both modern biomedical technology and a cultural form imitating biological processes, thereby causing mixed emotions. The mentioned ambivalence of altruistic and commercial surrogacy is also supported by sociological research challenging this dichotomy through the concepts of biolabour (Pande 2020) or clinical labour (Cooper and Waldby 2014), which also includes unpaid or underpaid reproductive labour or reproductive donation.

The Swedish white paper Different Paths to Parenthood in 2016 disagreed with the Swedish National Council on Medical Ethics and argued against both altruistic and commercial surrogacy through the arguments of exploitation and threatened autonomy of women (SOU 2016:11; Guntram and Williams 2018b), thereby paving the way for the ongoing Swedish uterus transplantation experiments. After many years of debates whether surrogacy should be legalised, the Swedish Parliament approved in 2018 a proposal to uphold the ban on surrogacy within domestic health care. Social welfare authorities and courts were provided increased opportunities to establish paternity following surrogacy arrangements abroad. Through this policy development in Sweden, uterus transplantation was established as the preferable alternative to surrogacy in Swedish societal debate, which also resonates in the analysed medical articles.

Similar to how surrogacy was discursively framed as a success in Finland, the uterus transplantation experiments in Sweden were presented in several analysed medical journals as medical success story, particularly as a new infertility treatment producing healthy children. The reproductive aim of producing healthy children was central to discourse of routinisation of gestational surrogacy and uterus transplants. In the Swedish journal Läkartidningen, Professor Brännström emphasised uterus transplantation as a successful infertility treatment:

The ultimate purpose of uterus transplantation is to develop a successful treatment for absolute uterus infertility, which is the largest subgroup of female infertility where treatment is lacking (Brännström et al 2014, 2/Läkartidningen).

Head of research and development Grip at Sahlgrenska University Hospital expected gradual routinisation of uterus transplants in Swedish health care: “But if we continue, sooner or later we end up in a situation where we get patients referred to us. With each new step we take, the method becomes more established” (Ström, 2016/Läkartidningen). As noted by Rose (2007b, p. 82), biomedicine focuses on enhancement by attempting to optimise or improve the human body. Reproductive technologies are future-oriented, focusing on enhancement of fertility (Rose 2007b, p. 20). Likewise, a Swedish uterus transplant recipient subjectively represented the procedure as an infertility treatment:

Uterus transplantation is not so much a transplant as it is an infertility treatment. The body function that was taken from me, and which I need to be able to have a baby, can be restored. Uterus transplantation is the only treatment that functions as an adequate substitute for the natural method, and patients with uterus infertility can no longer be denied this. With uterus transplantation, we are given the same opportunity as other women to become pregnant (Vall 2019, 1204/AOGS).

Hence, the transplant recipient Vall referred to equal opportunities to pregnancy and a restorative aim as arguments for uterus transplantation. For her, the transplant was a success: “I have had two wonderful children and the future that I once imagined” (Vall 2019, 1204/AOGS). By including the reproductive aim, uterus transplants differ from other organ transplants with the medical purpose of saving or prolonging the recipient’s life. Lacking the life-saving purpose, uterus transplants’ legitimacy was pursued in the above example through emphasis on the creation of new life. Thus, this exemplifies how uterus transplants were domesticated in medical journals through association with bio-intimate structures of kinship, gender, and reproduction (cf. Franklin 2013).

The biomedicalised diagnosis of absolute uterine factor infertility and its treatments

The comparability of surrogacy and uterus transplantation was emphasised in the analysed journal articles through biomedicalisation of the diagnosis absolute uterine factor infertility (AUI). Women diagnosed with AUI cannot become pregnant without uterus transplantation. Authors of an original article on plastic surgery of malformations of female genitalia in the Swedish journal Läkartidningen wrote:

Since these women have no uterus or a rudimentary uterus, they cannot on their own become pregnant and give birth. This absolute infertility strongly motivates that the women during examination and follow up get in contact with a gynaecologist with special interest in reproductive medicine (Frost-Arner et al 2004, 2895/Läkartidningen).

The authors concluded that the only legal and available option in Sweden at the time was adoption. Hence, the authors did not articulate how gynaecologists should assist women with AUI. In the early 2000s, surrogacy and adoption were often mentioned as relevant alternatives for AUI patients (e.g. Heinonen 2006/Duodecim), because uterus transplantations had been done only in animal experiments. However, since 2010, surrogacy and uterus transplantation were frequently compared. A Swedish debate article, criticising uterus transplantation and advocating surrogacy, mentioned the uterus as an “extremely loaded female organ” (Hallén et al 2010, 2903/Läkartidningen). The authors concluded about uterus transplantation: “After a successful pregnancy, the uterus is taken out. We then have two infertile women” (Hallén et al 2010, 2904/Läkartidningen). The claim is an interesting example of symbolic representations of the uterus, using biomedicalising rhetoric of infertility categories. Hence, an infertility diagnosis was attached to both the donor and the recipient as women without a uterus. However, the authors disregarded the context of uterus transplantation because most Swedish donors have been post-menopausal. Other articles mention that Brännström’s research team has also experimented with uteri from deceased donors, thus reducing the accuracy of the claim of two infertile women (Bokström et al 2016/Läkartidningen).

The discourse on absolute infertility was influenced by biomedicalisation of women’s reproduction and might contribute to treatment inaccessibility (cf. Bell 2010). Finnish medical discourse connected interdiscursively to Finnish political discourse on surrogacy, which before the Ministry of Justice’s (2023) report has rarely acknowledged same-sex couples, single men or those who are infertile due to old age or unclear reasons as potential parents through surrogacy (Eriksson 2022). Medical journal authors advocating legalisation of surrogacy in Finland have quite consistently focused on infertile heterosexual couples, particularly women with AUI. However, women with a diagnosis of AUI were thus given an ambivalent fertility status, as their infertility involved the uterus, and not necessarily the ovaries, which represented the possibility of genetic offspring. For example, the Finnish physician Söderström-Anttila (2014/Läkartidningen) mentioned: “[s]ome young fertile women with normally functioning ovaries lose their uterus during childbirth complications or diseases of the uterus”. In another article, Söderström-Anttila estimated that surrogacy would concern only a few Finnish women annually, because she defined the need for gestational surrogacy on medical grounds:

According to her [Söderström-Anttila], the most convenient would be to limit the possibility, at least initially, to otherwise healthy young women, to whom giving birth is impossible because of the absence of a uterus or other serious abnormality of the uterus (Vehmanen 2013, 647/SLL).

The expression “otherwise healthy young women” gave the impression that these women still were fertile in some respect despite the absent or abnormal uterus. Their ambivalent reproductive status was used as an argument for including surrogacy in Finland’s publicly funded health care. However, in the same interview article, the physician Halila mentioned male same-sex couples and questioned “why the absence of the uterus, or a structural defect in the mother, should be the only justification [for surrogacy]” (Vehmanen 2013, 647/SLL). She thereby opened the discussion to equality arguments and acknowledged that strict limitation of treatment access reinforced hegemonic family and kinship norms.

Reproductive donation and bio-intimacy in close relationships

The relational dimension of surrogacy and uterus transplantation was discussed in the medical journals in relation to the risk of pressure and threat to women’s autonomy and the benefits of familial reciprocity and compassion. The risk of pressure in reproductive donation between family members was a leading argument against legalisation of altruistic surrogacy in the Swedish white paper (SOU 2016:11, 32, 392; Guntram and Williams 2018b). The pressure argument was also addressed by executive director Pälve at the Finnish Medical Association in an interview:

Pressure may arise between relatives; in which case the expected delivering woman cannot act of her own free will without breaking her intimate relationships forever. It is not possible to without any problem create such a binding situation between the delivering woman and the biological parents so that the contracts will definitely last until the end (Alarotu 2013, 161/SLL).

Pälve assumed that altruistic surrogacy has severe consequences for intimate relationships. His claim had a high degree of modality by using the resolute expressions “forever” and “not possible” and “definitely”. In a Swedish debate article, the social scientists Guntram and Williams (2018a/Läkartidningen; 2018b) challenged biomedical discourse by arguing that uterus transplants with live donors involve similar ethical concerns as altruistic surrogacy, for example, threats to autonomy, risk of pressure from close relatives, or exploitation of donors. My analysis suggests that most medical articles primarily associated medical risks and general uncertainty with uterus transplants, while surrogacy was primarily associated with social and emotional risks, such as perceptions about kinship or self-determination. In a commentary by another non-health care professional, a Swedish uterus transplant recipient questioned the idea of sharing biological motherhood with a surrogate:

Personally, I would have had a harder time relating to a relationship in which a woman will be carrying and giving birth to my baby […], than to the relationship with a woman who donates an organ. Uterus transplantation is, I believe, the method that requires the least involvement of other people and that is least emotionally stressful. (Vall 2019, 1204/AOGS)

According to the transplant recipient, uterus transplants are less associated with mothering and kinship, because they require less involvement. She downplayed the risk of family members being pressured to uterus donation by emphasising the altruistic ideal of reproductive donation as “doing good deeds” (Vall 2019, 1204/AOGS). Most of all, these mentioned quotations exemplify how bio-intimacy in reproductive donation involves unresolved and ambivalent emotions that would require further comparative analyses of surrogacy and uterus donation.

From innovation to cultural adaptation of uterus transplantation

In this section, I deepen the analysis of how representations of uterus transplantation were developed through cultural adaption in relation to progress of the clinical trials. Uterus transplantation was often mentioned in a context of medical research, scientific progress, and advances of biotechnology. In a commentary, Professor Brännström told a story about how he came up with the idea for the uterus transplantation project. He met a patient in Australia, Angela, who planted this idea in his mind.

Apparently, she had a solution-oriented mind and quickly responded to us: I know the solution to the problem – you can transplant the womb from my mother. We were astonished by her suggestion since this was a concept that had not been in our minds before. […] How did Angela come up with this totally new concept? (Brännström, 2015, 676/AOGS)

In this quotation, Brännström introduced uterus transplantation as an innovation. By connecting Angela to the event of innovating uterus transplantation, he represented it as a new concept, or “the solution to the problem” – a truth claim with very high modality. The discursive framing constructed patient demand as the cause of this innovation, which was central to how uterus transplants were legitimated at the expense of surrogacy or adoption:

There is a strong clinical interest and demand by patients for uterus transplantation. The acceptance of the procedure as an infertility treatment for women with absolute uterine factor infertility is high, and even in countries that permit surrogacy, such as the UK, it is preferred by patients over gestational surrogacy and adoption (Benedet 2019, 1206/AOGS).

Several medical articles referred to a Swedish survey of women’s attitudes to ART, which found more positive attitudes to uterus transplants (80%) than to surrogacy (47%) (Wennberg et al 2015/AOGS). Finnish health care professionals have also gradually presented uterus transplantation as an alternative to surrogacy in Finland. A Finnish article estimated that uterus transplantation eventually would replace surrogacy as a routinised treatment after hysterectomy: “Because surrogacy is prohibited in many countries, uterus transplantation is also expected to become more common for cancer patients” (Pakarinen and Ranta 2018/SLL). A Finnish editorial evaluated the cultural adaptation of uterus transplantation by first representing it as innovation: “This new innovation might offer a spark of hope” (Mäkisalo and Ylikorkala 2015, p. 10/Duodecim). They reported successful trials in Sweden, summarising it as: “Nice story and a happy ending” (Mäkisalo and Ylikorkala 2015, 10/Duodecim). However, after reflecting on multiple risks involved in uterus transplantation with subsequent risky pregnancy, they concluded:

Uterus transplantation is today not a realistic option for treating these women, and it hardly ever will be, as it is an expensive and risky procedure. It would be wisest to change the law to allow surrogacy in the treatment of women with congenital uterus deficiency (Mäkisalo and Ylikorkala 2015, 11/Duodecim).

These Finnish authors disregarded uterus transplants as a promising but unrealistic, expensive, and risky treatment option, while arguing that surrogacy can be routinised in Finnish health care. The authors’ conclusion is consistent with the biomedicalised legitimation of surrogacy by Finnish many health care professionals, as presented previously. However, four years later, the sceptics Mäkisalo and his colleagues were impressed by uterus transplantation:

The good results amazed the transplant world and us sceptics. Many changed their minds and began to view uterus transplantation as a real option for women of childbearing age living without a uterus (Mäkisalo et al 2019, 2411/Duodecim).

The quotation illustrates a change of attitudes, which potentially might be part of a wider ongoing discursive change, by which uterus transplants increasingly are being considered as culturally adapted and routinised treatments in a Nordic context.

This article examined twenty years of discursive struggles in Nordic medical journals around the process of legitimating and routinising gestational surrogacy and uterus transplantation in Finland and Sweden through tensions between routinisation and resistance. Gestational surrogacy and uterus transplantation were biomedicalised through technoscientific biomedical innovation, knowledge production, diagnosing, and categorising of infertility, but they were also domesticated through association with established bio-intimate structures of kinship and gender, such as genetic relatedness, and pregnancy and birth as central parts of being female (cf. Kroløkke and Petersen 2017). The study demonstrated that since around 2010, and the increasing success of Swedish uterus transplantation trials, women’s non-conforming bodies diagnosed with AUI became objects of biomedical knowledge production and public health strategies with surrogacy in Finland and uterus transplantation in Sweden as preferred means for achieving biogenetic kinship. Despite being absolutely infertile, these women’s infertility was redefined through biomedicalisation of new technoscientific identities (Clarke et al 2003, 2010) as the last patient category that was lacking ART treatment.

Through biomedicalising discourse, surrogacy was by Finnish health care professionals represented as a more routinised procedure, particularly in Finland where it was previously practised (Söderström-Anttila et al 2002). This suggests that these non-conforming women’s bodies were depicted as being on the boundary between fertile and infertile, as they may have functioning ovaries. Through the rhetoric of women’s equal opportunities to biogenetic motherhood, these women’s ambiguous reproductive status was used to legitimise unpaid gestational surrogacy in Finland and uterus transplantation in Sweden. Through biomedicalising rhetoric, both practices were represented as infertility treatments and were associated with other more routinised ARTs (Thompson 2005, pp. 79–81; Franklin 2013, p. 6). The countries’ main differences in medical discourse—prioritising surrogacy in Finland, and successively prioritising uterus transplantation over surrogacy in Sweden—can be understood against the background of Sweden being a pioneer in uterus transplantation and Finland’s clinical practice of surrogacy in the years 1991–2007. Furthermore, medical discourse was developed in parallel with the countries’ policy development on surrogacy, in which Finland’s door to surrogacy in domestic health care has been kept ajar (Ministry of Justice 2023; Eriksson 2022), while Sweden’s door has been closed (SOU 2016:11; Gunnarsson Payne and Handelsman-Nielsen 2022).

The analysis focused on three processes of biomedicalisation (Clarke et al 2003, 2010): (1) the increasing technoscientific nature of biomedical innovations, especially through the innovation of uterus transplantation, which was represented as scientific progress and advances of biotechnology, (2) transformations of biomedical knowledge production and consumption through the active involvement of key medical professionals promoting surrogacy law reform in Finland and the routinisation of uterus transplantation in Sweden, and (3) the transformations of bodies in relation to new technoscientific identities by defining surrogacy and uterus transplantation as infertility treatments for AUI patients.

An inherent problem in the biomedicalisation of surrogacy and uterus transplantation, as expressed in the Nordic medical journal discussions, is the identification of a narrow patient category of women with AUI. Several authors discussed uterus transplants or gestational surrogacy in the context of medical advances, which can help women with uterus deficiency to have a genetic child, and the importance of genetic bonds was rarely questioned. Through the diagnosis of AUI, the uterus became the primary focus in women’s infertile bodies, while homosexuality and infertility unrelated to the uterus were less acknowledged reasons in medical discourse for attempting surrogacy. The narrow patient category is reasonable in relation to uterus transplantation with the aim of making gestation possible, and this was also justified by clinical interest and patient demand, while it can be perceived as discriminatory in relation to surrogacy from an equality perspective. Hence, despite successful biomedicalisation of surrogacy in Finland’s public debates on surrogacy, a report by the Ministry of Justice (2023) stated that surrogacy should be available for intended parents regardless of marital status or gender, thereby abandoning the narrow biomedical focus on AUI patients.

Uterus transplantation is a rare biomedical innovation, because most biomedical advances are small adjustments of existing procedures, while this method involves several advanced surgeries, which are considered successful if they contribute to one or more successful pregnancies. The findings suggest that uterus transplantations have gradually become more accepted within the medical profession in Finland and Sweden, and some former sceptics claimed to have changed their minds. Moral discourse of risk assessment is central to cultural adaptation of reproductive technologies in general and to the discursive positioning of gestational surrogacy against uterus transplants. As noted by Lie and Lykke (2016, 17), there are counterforces in processes of routinisation of ART through strategies of resistance or restriction through state regulations and cultural and religious belief systems.

However, analyses of the relational dynamics in uterus transplantation are still underdeveloped. Based on my analysis, the common discursive framings of surrogacy as exploitation/inequality and opportunity/choice (Markens 2012; Rudrappa and Collins 2014) are not yet common in Nordic medical discourse in relation to uterus donation in close relationships, despite being comparable situations of reproductive donation. Bio-intimacy (Kroløkke and Petersen 2017) in reproductive donation may involve social and emotional risks regarding reproductive autonomy, risks of someone being pressured or exploited, and a reciprocal impact on the relationship after donation. Nordic medical journals authors represented surrogacy as ambivalent bio-intimate acts between donors, recipients, or family members, based on compassion or pressure. Hence, these effects on the relational dynamics were in medical discourse primarily discussed in relation to surrogacy, and not uterus transplantation. This suggests that further risk assessment is required before introducing uterus transplantation as routine treatment beyond the experimental phase (Guntram and Williams 2018b). I suggest that relational dynamics including potential risks and benefits of reproductive donation in close relationships should be studied further through other methods, giving voice to the women involved in surrogacy arrangements and uterus donation.