According to a recent study, about 1.6 million adults (ages 18 and older) and youth (ages 13-17) identify as transgender in the United States, or 0.6% of those age 13 and older (asamonitor.pub/3Vz9zGO). These numbers make it likely that anesthesiologists will care for transgender patients, whether in transition for gender confirmation surgery (GCS) or routine procedures. Therefore, it’s important to understand how to provide safe and culturally sensitive perioperative care for transgender patients.
Sex ≠ gender
“Sex and gender are two different concepts, and anesthesiologists should be cognizant of these differences,” said Alopi M. Patel, MD, Assistant Professor, Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York. “Sex is assigned at birth based on physical characteristics such as hormones, chromosomes, and reproductive organs. Gender is a social construct and may not always be the same as the assigned sex. A transgender person is someone whose gender identity isn’t congruent with the sex they were assigned at birth.”
Physicians should avoid thinking gender is limited to just man or woman, as this is a Western construct. Rather, gender is considered a continuum along which a person’s gender may fall anywhere, everywhere, or nowhere. According to the literature, there is an evolving array of terms to describe one’s gender or genders and more freedom to express characteristics such as movement, dress, and mannerisms in ways commonly referred to as masculine, feminine, neither, or both (Anesth Analg 2018;127:359-66).
In addition, being transgender is not dependent upon physical appearance or medical procedures. A person can call themselves transgender the moment they realize their gender identity is different than the sex they were assigned at birth (https://asamonitor.pub/3Cu7l44).
Caring for the whole patient
Transgender patients require special consideration because of distinctive health risks, specific health care needs, and health care disparities. “Transgender patients encounter discrimination, transphobia, and microaggressions, all of which are associated with high rates of mood disorders, substance abuse, suicide attempts, and sexually transmitted infections, so culturally competent health care is especially important,” stated Dr. Patel, who also hosts The Hurt podcast by The Female Pain Docs, which is dedicated to discussing topics relating to women’s pain and general health (asamonitor.pub/3F5kXmB).
The first thing anesthesiologists can do is use the right language. “I Google what terms to use, and I also check the GLAAD media website regularly for guidance because even terms we were using a year ago might no longer be preferred,” advised Dr. Patel. “Just asking a patient how they like to be addressed is an easy way to start, as is using your pronouns at the end of an email. Understand you may misspeak. Don’t be afraid to talk about something because you fear making a mistake. Trying to be supportive and accepting shows that you’re a nonjudgmental ally.”
In addition to showing cultural competence and sensitivity, the anesthesiologist must also provide medically appropriate care for transgender patients. The anesthesiologist will need to know if the patient is using binding or tucking techniques or hormone therapy and if they have undergone any gender-confirming surgery.
“Binding can compress the thorax and cause airway issues. Tucking can cause mechanical damage due to pulling or tearing, and urinary trauma or infections. Estrogen can affect the risk for deep vein thrombosis (DVT), increase pain, postop nausea, and vomiting. Patients taking testosterone may be at a higher risk for heart attack. Regarding gender confirmation surgery, you’d need to know if they have had any procedures, and, if so, what type. Even something like feminization or masculinization laryngoplasty can affect the airways, which is critical for anesthesiologists to know,” she shared.
