Radius Anesthesia blog Dec 2019
Transgender is an umbrella term that describes people whose gender identity and/or gender expression differs from what is typically associated with the sex they were assigned at birth.1 Some researchers estimate that one million adults in the United States and 25 million adults worldwide identify as transgender, and that future surveys are likely to observe even higher numbers of transgender people.2,3 Transgender people have unique health conditions and experience various sociocultural stressors; thus, health professionals must be sure to provide culturally sensitive health care to transgender patients.4 In gender confirmation surgery and other types of procedures, anesthesia providers play an integral role in the health care of transgender patients.3 Not only should anesthesiology practitioners exercise cultural competence with transgender patients, but they must also account for special health risks that may affect anesthesia administration.
Culturally competent health care is important for all patient populations, and especially for transgender patients. Transgender individuals face discrimination and marginalization in many societal contexts.4 Transgender patients regularly encounter transphobia, enacted and perceived stigma and microaggressions, all of which are associated with adverse health outcomes, such as high rates of mood disorders, substance abuse, suicide attempts and sexually transmitted infections.3-5 Specifically in the health sector, the transgender community is highly underserved.6 Challenges for transgender patients include structural and financial barriers, as well as lack of health professional experience.6 Stigmatization may lead transgender patients to refrain from disclosing their gender identity, which could have poor consequences due to lack of proper medical history.6 Additionally, contemporary structures in health care settings, such as electronic health records, may lack the mechanisms to track transition information.6,7 Finally, health care providers do not have adequate information regarding unique health risks and long-term outcomes for transgender patients, which leads to unsatisfactory care.6 Overall, health care for transgender patients needs improvement.
Anesthesiologists can take critical steps to improve health care experiences for transgender patients. During the preoperative period, the anesthesia provider should assess the patient’s gender identification and preferred pronouns, while also noting incongruencies in legal names or genders on identification documents.3 One study found that certified registered nurse anesthetists (CRNAs) showed disconnect and discomfort about asking tough questions, hindering their ability to develop trusting relationships with transgender patients.7 Openness and a nonjudgmental attitude are crucial to making the patient more comfortable and creating a healthy preoperative environment.3 Also, the anesthesia provider may need to perform a physical examination, which can be a distressing experience for the transgender patient.8 To preserve dignity, the patient should be allowed to have a chaperone present and the anesthesiologist should only conduct an examination when physically necessary.3 Throughout the intraoperative and postoperative periods, the anesthesia provider should continue to use the patient’s preferred gender identity, preferred name and preferred pronouns.4 Transgender patients should be roomed in accordance with their gender identities and postoperative discussions with family should be sensitive to the group’s dynamics.3 Clearly, the whole perioperative period should be marked by a nondiscriminatory, understanding environment.
In addition to showing cultural competence and sensitivity, the anesthesiologist must also provide medically accurate care for transgender patients. Preoperatively, the anesthesiology practitioner must evaluate the hormonal therapies (HTs) a transgender patient may be using for medical transition, as these can have an effect on choices of anesthesia.3,9 An anesthesiologist should also perform laboratory tests—including assessing HIV and pregnancy statuses—to prepare for adequate care.3 During the procedure, anesthesia providers should monitor their patients with utmost vigilance. Transgender patients may be at risk for venous thromboembolism (VTE) during surgery, as HT can increase rates of VTE.3 Other intraoperative factors include anatomical considerations and cardiovascular complications.3 Postoperatively, the anesthesiologist must perform laboratory tests and consult with the patient before restarting HT.10 Individualized pain management, physical therapy and mental health follow-ups are especially important for transgender patients given substance abuse rates and outside stressors.3
Overall, the anesthesia provider is responsible for providing culturally sensitive, medically satisfactory care before, during and after a transgender patient’s procedure. Future studies should assess anesthesia providers’ awareness of transgender issues. Once researchers find effective ways to fill knowledge gaps, they should aim to develop courses on care for transgender patients.
1. GLAAD. Glossary of Terms—Transgender. 2019;
2. Meerwijk EL, Sevelius JM. Transgender Population Size in the United States: A Meta-Regression of Population-Based Probability Samples. American Journal of Public Health. 2017;107(2):e1–e8.
3. Tollinche LE, Walters CB, Radix A, et al. The Perioperative Care of the Transgender Patient. Anesthesia & Analgesia. 2018;127(2):359–366.
4. Bishop BM. Pharmacotherapy Considerations in the Management of Transgender Patients: A Brief Review. Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy. 2015;35(12):1130–1139.
5. Graham R, Berkowitz B, Blum R, et al. The health of lesbian, gay, bisexual, and transgender people: Building a foundation for better understanding. Washington, DC: Institute of Medicine. 2011:89–139.
6. Roberts TK, Fantz CR. Barriers to quality health care for the transgender population. Clinical Biochemistry. 2014;47(10):983–987.
7. Hatfield MG. Anesthesia Providers’ Discovery of Patients’ Gender Identity. The University of Arizona; 2017.
8. Makadon HJ, Mayer KH, Physicians ACo, Potter J, Goldhammer H, Mayer K. The Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health. American College of Physicians; 2008.
9. Tsai MH, Balla A, Tharp WG. Intraoperative Considerations for Transgender Patients. Anesthesia & Analgesia. 2018;127(6):e109.
10. Shah SB, Khanna P, Bhatt R, Goyal P, Garg R, Chawla R. Perioperative anaesthetic concerns in transgender patients: Indian perspective. Indian Journal of Anaesthesia. 2019;63(2):84–91.