The CROWN Initiative

Medical research is bedevilled by the difficulty in comparing the outcomes of different projects as the chosen research methods and endpoints can vary considerably, even when at first sight they appear to be the same. Professor Khalid Khan, the Editor-in-Chief of BJOG: An International Journal of Obstetrics & Gynaecology, has coordinated a plan to develop core outcome sets in gynaecology, obstetrics and reproductive health and this has been agreed to by almost 60 journals in our specialty worldwide, including the Journal of Family Planning and Reproductive Health Care. The Editorial in this issue sets out the aims of CROWN and will appear in all participating journals this autumn. The challenge now is for us to develop and agree on those outcome sets and to ensure that future research articles conform to them. The expression ‘herding cats’ comes the mind of your outgoing Acting Editor-in-Chief! See page 239

Contraception following bariatric surgery

Surgery to combat obesity is in the news, with draft NICE guidelines suggesting that the number of operations offered in the NHS should increase, and, perhaps more significantly for some of our clients, the host of Woman's Hour announcing that she plans to undergo bariatric surgery herself. The health benefits of surgery can be significant, but the rapid weight loss and changes in digestive physiology that follow surgery can have a profound influence on reproductive health, both in relation to contraception and to pregnancy. Graham et al.'s very timely commentary, Contraceptive needs of women following bariatric surgery, is a comprehensive review of the nature and consequences of bariatric surgical procedures and gives clear advice regarding optimal approaches to contraception for such patients. See page 241

Man matters

This issue is a little unusual in that no less than five of our articles deal with men – or in the case of one of the articles, trans people, whose male (or female) sex assigned at birth does not align with their gender identity.

The first three articles deal with heterosexual men. In High and low contraceptive use among male young offenders: a qualitative interview study Buston et al. report on their interviews with young male prisoners. Their paper provides important insights into a marginalised group with high rates of fatherhood and sexually transmitted infections (STIs). In semi-structured interviews they found ‘high’ condom users who had a strong desire to protect themselves and their ‘manliness’ and ‘non’ or ‘low’ users who emphasised pleasure, and fatalism about the consequences. Their very different views of condom use suggested that an effective intervention with the low users might be the narrative of self-protection. Working with these young men while in prison could yield significant benefits. See page 248

What influences the risk of STI acquisition among heterosexual men? August et al. studied a large sample of men aged 18–70 years and report on this in Age-related variation in sexual behaviours among heterosexual men residing in Brazil, Mexico and the United States. They found that STI risk factors varied by age-related life experiences. Their study underscores the importance of research regarding sexual behaviours and risk among heterosexual men and they suggest that their findings warrant support for the development of targeted public health interventions to reduce adverse sexual health outcomes. See page 261

And what of those who do want to become fathers? Three of the articles deal with potential parenthood. Among heterosexual males, does waiting for fatherhood have any disadvantages? Lawson and Fletcher's fascinating review, Delayed Fatherhood, highlights literature on sperm quality, pregnancy complications, congenital anomalies and the long-term health of the child. Paternal age at conception is a possible contributor both to complications during pregnancy and birth and to a number of conditions in the offspring. The authors acknowledge the difficulty in interpreting findings due to confounding factors, but they also discuss the benefits and challenges of becoming an older father. See page 283

One might not expect the subjects of the remaining two articles in this group to wish to become parents, but reproductive desire is strong in all segments of society. In Gay fathers' reproductive journeys and parenting experiences: a review of research, Riggs and Due explore the ways in which gay men can become parents. They may face many hurdles in reaching their goal, but when they achieve parenthood the evidence is that their children do as well as children in heterosexual parent families. Reproductive health clinicians may encounter clients within such relationships at many stages in those reproductive journeys and they need to keep an open mind during these interactions. The information here will assist greatly in understanding the complex issues that may come to light. See page 289

Finally, in Trans people's reproductive outcomes and options, Richards and Seal, who are among the foremost British workers in this area, take us carefully through the complex issues raised if members of this group wish to have children. The options for people who seek to change their gender vary according to cultural context, but in developed societies with hormonal and surgical assistance fairly readily available, people who choose to transition will often create a body that is more congruent with their perception of themselves as women or men. Because of the almost inevitable infertility that will result, advice on reproduction is therefore an integral part of the transition process and relevant professionals need be able to offer informed support. See page 245

Integrating family planning and GUM services

UK policy advocates integrated approaches to sexual health service provision to ensure that everyone can access high-quality treatment. But what are the resultant benefits, and what do staff themselves think? Higgins et al. asked clinic staff in one Scottish region to complete anonymous questionnaires before and after integration and conclude that evaluation of staff experiences of service redesign can provide valuable insights for ongoing quality improvement and can help with the development of pathways to deliver better outcomes. See page 254

Adolescent sexual health education in Iran…

Iran is a fascinating country to the outside observer. Although a pariah state to the Western world for over 30 years, it was one of the world's first civilisations and despite the current dominance of the Islamic religion it continues to have a flourishing cultural life, to which women have made a significant contribution. Shariati et al. report on their research among adolescent girls and key adults (ranging from mothers to religious leaders and government representatives), looking at barriers to girls' access to sexual and reproductive healthcare (SRH) information and services. They conclude that adolescent SRH should be a priority for their country's leaders and policymakers, with the caveat that they should try to provide “those services that are consistent with the community's cultural and religious values”. In the circumstances this was ground-breaking research and the findings give an insight into a very different world. See page 270

…and adolescent STI incidence in Ireland

The burden of STIs rests with young people, yet in Ireland there has been very little research into this population. Davoren et al. conducted a study to determine the incidence rate and to establish risk factors that predicted STI occurrence among adolescents. They found that the incidence of STIs was high, and they also found a high level of risk-taking behaviour (smoking and alcohol use). Not surprisingly, there was a strong association of STI risk with non-use of condoms. They suggest that an integrated public health approach is needed to combat such risk-taking in the adolescent population. See page 276

CHCs following lung transplantation

A patient new to your practice requests a repeat prescription of her combined pill. You find that she had a bilateral lung transplant 2 years ago, that she has been on a combined hormonal contraceptive (CHC) for the last year and she does not want to change. Is it safe for her to continue? Bader et al. present a series of eight women who were using CHCs post-transplant and discuss the potential risks and benefits of continuing. While their findings are not definitive, and are inevitably confounded by selection bias, they generate some useful points for further research. See page 294

Twenty-five years ago: then and now

Our Advisory Editor, Professor Lindsay Edouard, continues his series reviewing the topics in this Journal a quarter of a century ago and comparing them with current issues. Here he reminds us of the 1989 crisis in UK family planning services due to proposed cuts in community clinics, and of the discussions on ethics in relation to the provision of abortion services. In 2014, abortion continues to cause controversy in international health, despite excellent guidance for the provision of abortion services from the World Health Organization. The outcome of current United Nations discussions will be crucial for the future safe provision of abortion services with their proven health benefits for women worldwide. See page 297

The 2014 Margaret Jackson Prize Essay

This year the FSRH's annual prize for essays by medical students was shared by two winners. Kundan Iqbal's essay, The impact of romance novels on women's sexual and reproductive health, is both entertaining and well-informed. Ideally, she says, romantic fiction could combine entertainment with sexual education by the promotion of realistic expectations and depictions of safer sexual practices. Ruth Harris's essay on the transition of adolescents with vertically transmitted HIV infection to adult services will appear in our January 2015 issue. See page 300

Gardening tips

Our Consumer Correspondent explores the issue of women's sexual fantasy through two books written four decades apart – and suggests that this comparison contains lessons of interest to us all. See page 303