Reproductive options

Within the Nottingham and Charing Cross gender clinics ‘triadic therapy’ is practised, meaning that more reversible changes are instigated before less reversible and irreversible ones. Thus one makes a change of gender role to present as one's felt gender and then starts hormones and then has chest surgery and then has genital surgery. Of course all of this is carefully managed, and an individual need not have all of these interventions if they do not want them. For the reasons given above, before initiating hormone or surgical treatment clients are counselled by psychologists, psychiatrists and/or endocrinologists regarding loss of fertility and they must consent to fertility loss before being recommended for hormone treatment.

Some trans men and women elect not to undergo genital surgery and/or removal of reproductive capacity and should they so choose they can therefore achieve pregnancy without assisted reproductive technologies. Hormonal interventions are often largely reversible, but it may take from 3 to 24 months after withdrawal of hormone treatment until reproductive functioning returns to normal. This means that those gendered characteristics that were being suppressed by a hormonal regimen will re-emerge and professional support is often crucial throughout this period. There may also be difficulties in accessing health care in such a gendered environment as reproductive medicine, and sensitive handling of this situation is important.

If trans people wish to store gametes, whether for use with a surrogate or with a fertile partner, harvesting is usually commissioned by the National Health Service (NHS) national commissioning for trans services, although cryostorage is usually undertaken privately as it is not financed by the NHS, and so has a cost implication that can be a barrier for some trans people. There is a reasonable chance of a live birth from trans women's sperm storage, in contrast to the chances for trans men who have approximately a 4.0–13.6% chance of a live birth from cryopreservation of their gametes, which is half the live birth rate from using fresh oocytes.5 ,6 Obtaining the gametes for cryopreservation is more invasive for trans men than for trans women, as standard oocyte induction and collection is needed, which can be both physically and psychologically arduous. Both trans men and trans women can feel dissuaded by the apparently gendered nature of the endeavour7 (trans women will often need to attend an andrology clinic, for example) and careful discussion around the implications of not undergoing that discomfort are most important. Similarly, some trans people misunderstand the nature of eggs and sperm, seeing them as inextricably gendered rather than merely vessels for strands of DNA. A more technical and less culturally construed consideration of these matters can help some trans people re-evaluate any culturally-received ideas they may have and so make a decision based on their reproductive wishes.

These discussions are extremely important for younger trans people who at the age of 18 years may make decisions, based on an understandable wish to transition as quickly as possible, which their 30-year-old selves may regret when left without the possibility of having their own biologically-related children. Indeed, after starting hormones with the resultant attenuation of gender dysphoria, younger clients especially occasionally decide that they do wish to store gametes after all. Additionally, it is not uncommon for younger trans people to see adoption as a simple solution for their reproductive needs.4 While adoption is indeed a possibility for trans people, it is not without its difficulties due to the prejudices that still sadly persist in the minds of some professionals, and so should be thought through carefully with the individual. Many clients confuse the question of whether they wish to have the option of having children, which is the matter at hand, with whether they want to have children now, and this can usefully be disentangled in the consulting room.

Some trans people opt not to have gamete storage at any point as they have concerns that as they are trans they would not be fit parents This may be reflective of internalised transphobia,4 which is the state in which some trans people are themselves uncomfortable about, or phobic of, trans people. It is to this issue of trans parents that we now turn.

Children

There is no evidence that having a trans parent or caregiver harms children8^–10 or indeed appears to affect their sexuality or gender.10 Although any acrimony between the parents or caregivers around the transition can lead to psychological difficulties for the children, this is not a trans-specific issue as acrimony between parents or caregivers on any matter can cause psychological difficulties for their children.8 Some professionals have argued that children of trans parents or caregivers may be subject to bullying and should therefore not be cared for by them. However, one would never think of removing a child from a minority ethnic or gay parent on grounds of bullying and the same should reasonably be held to be the case here. Instead, robust anti-bullying measures should be in place at the school. Indeed as trans identity is a protected characteristic in discrimination law, such discrimination would be construed as indirect transphobia. Arguments around it being parental choice to transition are false as, in most cases, the decision to transition is not based on choice but rather on a biological aetiology.4 Similarly false are notions that trans people have higher degrees of psychopathology than the general population.4 The literature and our own clinical experience shows that trans people are just as good parents as cisgender people (those who are content to remain the gender to which they were assigned at birth), and so have the same rights and responsibilities.