Trans people's reproductive options and outcomes.

To cite: Richards C, Seal L. J Fam Plann Reprod Health Care 2014;40:245–247. INTRODUCTION Trans people are those people whose sex assigned at birth does not align with their gender identity – a condition that can cause marked distress. Consequently, many trans people seek to change their gender, often permanently. Most usually that change is to male or female although sometimes the change is to a non-binary gender form. However, as the last of these is less usual this commentary will consider only trans people who identify as male or female. The options available to trans people vary according to cultural context and so this commentary considers such matters from a context in which hormonal and surgical assistance is comparatively readily available. Within such contexts, people who choose to transition often use hormones and surgery to create a body that is more congruent with their perception of themselves as men or women. Thus people assigned as female at birth who identify and live as men (trans men) may take testosterone in order to grow facial hair and thicker body hair, increase musculature, create a deeper voice and ensure the cessation of menses. If they have the genetic propensity they will go bald. They will commonly have surgery to remove their breasts and produce a male chest contour and, less commonly, to have a surgically constructed penis. They will also be likely to have a hysterectomy and oophorectomy. Those people assigned as male at birth who identify and live as women (trans women) may have androgen suppression as well as estrogens in order to develop breasts and a more female body contour. Body hair may lessen, but facial hair will need removing by electrolysis. Scalp hair loss will stop, but hair will not regrow and hairpieces may therefore be used. The masculine voice is not affected by estrogens and speech therapy and sometimes surgery can be used to address this. Approximately 60% of trans women request augmentation mammoplasty, in part because the phenotypic male chest is larger than the female chest and so breast growth secondary to hormone use appears smaller. Trans female hormone regimens induce erectile loss and oligo/ azoospermia. Trans women may also opt to have an orchidectomy and the surgical creation of a vagina. After transition of course, both trans men and trans women are best considered to be simply men or women, respectively, in circumstances where their trans status is irrelevant. In both trans men and trans women therefore, loss of reproductive capability will accompany the use of cross-sex hormones. Although usually reversible if the person elects to stop taking the hormones, this loss may be irreversible. There will certainly be a permanent loss of reproductive function if the person has an orchidectomy or a hysterectomy and oophorectomy. Consequently, issues around the capacity for reproduction are highly important in the decision-making processes concerning trans people’s transition, both for the individual and for the clinician. Several of the main bodies working in this field therefore recommend this topic for discussion between clinicians and people who are transitioning. 3 The decision-making process around fertility for a trans person can be complicated by some people’s perceptions around trans people having children at all. Trans people, and others, may feel that trans people are de facto not fit to have children, which may affect the decisions around transition for those trans people who already have children and who are considering living in another gender role; or the decision as to whether to store gametes prior to hormonal and/or surgical transition as in the examples above. As we shall see, parent(s) and caregivers being trans is in no way detrimental to children, COMMENTARY