All lawyers have heard the puzzle of “how many legs does a dog have if you call his tail a leg?” The puzzle is often misattributed to Abraham Lincoln, who used the puzzle at various times, including in jury speeches. The answer of course is: “Four. Saying that a tail is a leg does not make it a leg.” Quote investigators have traced the puzzle as far back as 1825, when newspapers quoted legislator John W. Hulbert as saying that something “reminded him of the story.”[1]
What do we call a person who becomes pregnant and delivers a baby?
A woman.
The current, trending fashion is to call such a person a PLP, a person who becomes pregnant and lactates. This façon de parler is particularly misleading if it is meant as an accommodation to the transgender population. Transgender women will not show up as pregnant or lactating, and transgender men will show up only if there transition is incomplete and has left them with functional female reproductive organs.
In 2010, Guinness World Records named Thomas Beatie the “World’s First Married Man to Give Birth.” Thomas Beatie is now legally a man, which is just another way of saying that he chose to identify as a man, and gained legal recognition for his choice. Beatie was born as a female, matured into a woman, and had ovaries and a uterus. Beatie was, in other words, biologically a female when she went through puberty and became biologically a woman.
Beatie underwent partial gender reassignment surgery, consisting at least of double mastectomy, and taking testosterone replacement therapy (off label), but retained ovaries and a uterus.
Guinness makes a fine stout, and we may look upon it kindly for having nurtured the statistical thinking of William Sealy Gosset. Guinness, however, cannot make a dog have five legs simply by agreeing to call its tail a leg. Beatie was not the first pregnant man; rather he was the first person, born with functional female reproductive organs, to have his male gender identity recognized by a state, who then conceived and delivered a newborn. If Guinness wants to call this the first “legal man” to give birth, by semantic legerdemain, that is fine. Certainly we can and should publicly be respectful of transgendered persons, and work to prevent them from being harassed or embarrassed. There may well be many situations in which we would change our linguistic usage to acknowledge a transsexual male as the mother of a child.[2] We do not, however, have to change biology to suit their choices, or to make useless gestures to have them feel included when their inclusion is not relevant to important scientific and medical issues.
Sadly, the NASEM would impose this politico-semanticism upon us while addressing the serious issue whether women of child-bearing age should be included in clinical trials. At a recent workshop on “Developing a Framework to Address Legal, Ethical, Regulatory, and Policy Issues for Research Specific to Pregnant and Lactating Persons,”[3] the Academies introduced a particularly ugly neologism, “pregnant and lactating persons,” or PLP for short. The workshop reports:
“Approximately 4 million pregnant people in the United States give birth annually, and 70 percent of these individuals take at least one prescription medication during their pregnancy. Yet, pregnant and lactating persons are often excluded from clinical trials, and often have to make treatment decisions without an adequate understanding of the benefits and risks to themselves and their developing fetus or newborn baby. An ad hoc committee of the National Academies of Sciences, Engineering, and Medicine will develop a framework for addressing medicolegal and liability issues when planning or conducting research specific to pregnant and lactating persons.”[4]
The full report from NASEM, with fulsome use of the PLP phrase, is now available.[5]
J.K. Rowling is not the only one who is concerned about the erasure of the female from our discourse. Certainly we can acknowledge that transgenderism is real, without allowing the exception to erase biological facts about reproduction. After all, Guinness’s first pregnant “legal man” could not lactate, as a result of bilateral mastectomies, and thus the “legal man” was not a pregnant person who could lactate. And the pregnant “legal man” had functioning ovaries and uterus, which is not a matter of gender identity, but physiological functioning of biological female sex organs. Furthermore, including transgendered women, or “legal women,” without functional ovaries and uterus, in clinical trials will not answer difficult question about whether experimental therapies may harm women’s reproductive function or their offspring in utero or after birth.
The inclusion of women in clinical trials is a serious issue precisely because experimental therapies may hold risks for participating women’s offspring in utero. The law may not permit a proper informed consent by women for their conceptus. And because of the new latitude legislatures enjoy to impose religion-based bans on abortion, a women who conceives while taking an experimental drug may not be able to terminate her pregnancy that has been irreparably harmed by the drug.
The creation of the PLP category really confuses rather than elucidates how we answer the ethical and medical questions involved in testing new drugs or treatments for women. NASEM’s linguistic gerrymandering may allow some persons who have suffered from gender dysphoria to feel “included,” and perhaps to have their choices “validated,” but the inclusion of transgender women, or partially transgendered men, will not help answer the important questions facing clinical researchers. Taxpayers who fund NASEM and NIH deserve better clarity and judgment in the use of governmental funds in supporting clinical trials.
When and whence comes this PLP neologism? An N-Gram search shows that “pregnant person” was found in the database before 1975, and that the phrase has waxed and waned since.
N-Gram for pregnant person, conducted September 1, 2023
A search of the National Library of Medicine PubMed database found several dozen hits, virtually all within the last two years. The earliest use was in 1970,[6] with a recrudenscence 11 years later.[7]
From PubMed search for “pregnant person,” conducted Sept. 1, 2023
In 2021, the New England Journal of Medicine published a paper on the safety of Covid-19 vaccines in “pregnant persons.”[8] As of last year, the Association of American Medical Colleges sponsored a report about physicians advocating for inclusion of “pregnant people” in clinical trials, in a story that noted that “[p]regnant patients are often excluded from clinical trials for fear of causing harm to them or their babies, but leaders in maternal-fetal medicine say the lack of data can be even more harmful.”[9] And currently, the New York State Department of Health advises that “[d]ue to changes that occur during pregnancy, pregnant people may be more susceptible to viral respiratory infections.”[10]
The neologism of PLP was not always so. Back in the dark ages, 2008, the National Cancer Institute issued guidelines on the inclusion of pregnant and breast-feeding women in clinical trials.[11] As recently as June 2021, The World Health Organization was still old school in discussing “pregnant and lactating women.”[12] The same year, over a dozen female scientists, published a call to action about the inclusion of “pregnant women” in COVID-19 trials.[13]
Two years ago, I gingerly criticized the American Medical Association’s issuance of a linguistic manifesto on how physicians and scientists should use language to advance the Association’s notions of social justice.[14] I criticized the Association’s efforts at the time, but its guide to “correct” usage was devoid of the phrase “pregnant persons” or “lactating persons.”[15] Pregnancy is a function of sex, not of gender.
[1] “Suppose You Call a Sheep’s Tail a Leg, How Many Legs Will the Sheep Have?” QuoteResearch (Nov. 15, 2015).
[2] Sam Dylan More, “The pregnant man – an oxymoron?” 7 J. Gender Studies 319 (1998).
[3] National Academies of Sciences, Engineering, and Medicine, “Research with Pregnant and Lactating Persons: Mitigating Risk and Liability: Proceedings of a Workshop in Brief,” (2023).
[4] NASEM, “Research with Pregnant and Lactating Persons: Mitigating Risk and Liability: Proceedings of a Workshop–in Brief” (2023).
[5] National Academies of Sciences, Engineering, and Medicine, Inclusion of pregnant and lactating persons in clinical trials: Proceedings of a workshop (2023).
[6] W.K. Keller, “The pregnant person,” 68 J. Ky. Med. Ass’n 454 (1970).
[7] Vibiana M. Andrade, “The toxic workplace: Title VII protection for the potentially pregnant person,” 4 Harvard Women’s Law J. 71 (1981).
[8] Tom T. Shimabukuro, Shin Y. Kim, Tanya R. Myers, Pedro L. Moro, Titilope Oduyebo, Lakshmi Panagiotakopoulos, Paige L. Marquez, Christine K. Olson, Ruiling Liu, Karen T. Chang, Sascha R. Ellington, Veronica K. Burkel, et al., for the CDC v-safe COVID-19 Pregnancy Registry Team, “Preliminary Findings of mRNA Covid-19 Vaccine Safety in Pregnant Persons,” 384 New Engl. J. Med. 2273 (2021).
[9] Bridget Balch, “Prescribing without data: Doctors advocate for the inclusion of pregnant people in clinical research,” AAMC (Mar. 22, 2022).
[10] New York State Department of Health, “Pregnancy & COVID-19,” last visited August 31, 2023.
[11] NCI, “Guidelines Regarding the Inclusion of Pregnant and Breast-Feeding Women on Cancer Clinical Treatment Trials,” (May 29, 2008).
[12] WHO, “Update on WHO Interim recommendations on COVID-19 vaccination of pregnant and lactating women,” (June 10, 2021).
[13] Melanie M. Taylor, Loulou Kobeissi, Caron Kim, Avni Amin, Anna E Thorson, Nita B. Bellare, Vanessa Brizuela, Mercedes Bonet, Edna Kara, Soe Soe Thwin, Hamsadvani Kuganantham, Moazzam Ali, Olufemi T. Oladapo, Nathalie Broutet, “Inclusion of pregnant women in COVID-19 treatment trials: a review and global call to action,”9 Health Policy E366 (2021).
[14] American Medical Association, “Advancing Health Equity: A Guide to Language, Narrative and Concepts,” (2021); see Harriet Hall, “The AMA’s Guide to Politically Correct Language: Advancing Health Equity,” Science Based Medicine (Nov. 2, 2021).
[15] “When the American Medical Association Woke Up” (Nov.17, 2021).
