Perioperative considerations for transgender and gender diverse adults

By Victor Li

Key Reference:

Harding D, Marsh S, Lennie Y. Perioperative considerations for transgender and gender diverse adults. BJA Education. 2023;23(4):136-143. doi:https://doi.org/10.1016/j.bjae.2022.12.005

You are reviewing your patient list when you come across Ms Sue Doenim, a 23yo to be seen in the pre-admission clinic for an elective laparoscopic cholecystectomy. Upon meeting Sue, he informs you his pronouns are “he/him” and would prefer to go by the name “Stu”.

Why is this important?

An estimated 0.1% to 2% of the global population identify as transgender or non-binary. (1) The 2016 Census by the Australian Bureau of Statistics reported a rate of 5.4 per 100,000 people provided a valid and intentional sex/gender-diverse response (2). This is likely to be substantially under-reported for multiple reasons, including not having come out to their family, and operational challenges regarding gender identity on the paper form. A small pilot study by the ABS found a rate of 257 per 100,000 people provide a sex or gender response other than male or female – over fifty times as likely as the rest of Australia (2). According to the Royal Children’s Hospital, 1.2% of Australian schoolchildren are thought to identify as transgender (3). As societal awareness and acceptance of transgender and gender diverse individuals (TGDI) increase, an increasing number of people may feel comfortable to come out as transgender or gender non-binary, so these numbers are expected to increase.

Many TGDI have experienced significant traumatic events throughout their lives, which can negatively affect how they access and experience healthcare. In order to provide optimal patient-centred care and foster a respectful, trusting patient-practitioner relationship, it is imperative that clinicians are able to provide a safe environment where TGDI patients feel at ease and are able to express their gender identity without fear of prejudice. On the other hand, a poor interaction with clinicians who may lack understanding or harbour prejudices can cause TGDI to disengage with the healthcare system due to complex trauma and anxiety.

How can you best support Stu and other transgender and gender diverse individuals?

Anaesthetists can adopt a trauma-informed care approach to best support TGDI. This may include:

• Introducing yourself with your name, preferred pronouns and gender identity before asking for the name and pronouns of your patient.
• Avoiding mis-gendering or “dead-naming” the patient by using the incorrect pronouns or their previous name from before transitioning. If this does happen, apologise, acknowledge your mistake, and reassure them that you will make an effort to not repeat it.
• Asking only questions that are medically necessary.
• Asking the patient for their preferred terms for their genitalia.
• Limiting the number of healthcare providers involved in caring for the patient to only those that are necessary.
• Working collaboratively with the patient to make decisions to empower them and make their voice feel heard and respected in their own care.
• Offering a chaperone to be present for examinations and anaesthesia induction
• Offering care in a single room of a ward that is consistent with their gender identity to allow for sufficient privacy

What anaesthetic considerations are there in transgender and gender diverse individuals?

Transitioning refers to the process by which people change from the gender expression usually associated with their assigned sex at birth to another gender expression that better matches their gender identity. The extent of transitioning is highly variable and deeply personal to the individual. This can include social transitioning, whereby individuals change their name, pronouns, clothing, hairstyles or mannerisms, or it may also involve a combination of hormones and/or surgery to alter the physical body, or it may involve none of the above. Clinicians must therefore consider a range of physical, pharmacological, and surgical factors involved in gender affirmation therapy, and especially their impacts on peri-operative risk.

For all TGDI, adjustments may need to be made for total intravenous anaesthesia (TIVA) due to patient sex as a variable. Due to the limited data on how hormonal therapy affects anaesthetic drug pharmacokinetics, depth of anaesthesia monitoring is recommended for TIVA to allow early detection of inaccurate drug dosing.

Some specific considerations for transgender and gender diverse individuals are listed below.

	Examples of Gender-affirming therapy in TGDI Assigned Female at Birth (AFAB)	Anaesthetic Considerations
Physical transition	Chest binders to flatten chest tissue and create a masculine appearing chest	Risk of restrictive pattern of ventilation if left intra-operatively
Hormonal therapy	Exogenous testosterone for increased muscle mass, facial hair, cessation of menstruation, and voice deepening	Adverse side effects may include erythrocytosis, sleep apnoea, hypertension, weight gain, salt retention, and dyslipidaemia (4)
Surgery	Facial masculinisation surgery (e.g. mandibular angle augmentation, genioplasty) Thyroid augmentation Injection laryngoplasty	Crowding of structures in oropharynx may result in difficult airway management. Potential trauma to larynx and upper aero-digestive tract with airway instrumentation. Consider utilising laryngeal mask airway or microlaryngoscopy tube if airway instrumentation required Oedema of the larynx may necessitate smaller tracheal tubes

	Examples of Gender-affirming therapy in TGDI Assigned Male at Birth (AMAB)	Anaesthetic Considerations
Hormonal therapy	Oestradiol +/- cyproterone acetate, spironolactone or bicalutamide to minimise masculine sex characteristics and develop feminine secondary sex characteristics	Oestrogen therapy may influence volume of distribution of fat-soluble drugs due to fat redistribution (5) High oestrogen concentrations can reduce serum albumin, increasing the amount of free drug when using highly protein-bound drugs, e.g. bupivicaine (6) Oestrogen reduces plasma cholinesterase, which may cause suxamethonium to result in prolonged neuromuscular block (5) Adverse effects of cyproterone acetate include adrenocortical suppression, anaemia, and liver failure Spironolactone therapy can cause acute kidney injury, volume depletion, thrombocytopaenia, hepatic dysfunction, and warrants close monitoring of serum creatinine and potassium. Withholding spironolactone on day of surgery is recommended (5). Bicalutamide may inhibit CYP3A4, increasing plasma midazolam concentrations, and displaces warfarin from its protein binding sites, causing increased anticoagulation. (7) Other adverse effects of bicalutamide include nausea, angioedema, QT-prolongation (5) Consider risk factors for venous thromboembolism Prescribe appropriate anti-emetics for increased likelihood of post-operative nausea and vomiting
Gender-affirming surgery	Facial feminisation surgery (e.g. mandibular reduction, genioplasty) Thyroid reduction surgery Voice surgery	Crowding of structures in oropharynx may result in difficult airway management Reduced diameter of the upper aerodigestive tract Scar tissue may distort the anatomy of the upper airway, making identification of the cricothyroid membrane more difficult in event of cricothyroidectomy

 

 

 

 

 

 

 

 

What other peri-operative risk factors need to be considered?

Many perioperative risk calculators use patient sex as a variable in the calculation of morbidity and mortality. However, the temptation to use the higher scoring ‘male’ option for all individuals may be incredibly triggering for some TGDI, and lead to patient dissatisfaction. As a result, common risk calculators like the STOP-BANG criteria for obstructive sleep apnoea may have reduced applicability in TGDI.

Furthermore, hormone therapy may alter patient blood test results, thus indirectly impacting risk stratification, post-operative management, and choice of anaesthesia. Oestrogen therapy causes reduced haemoglobin, haematocrit, and creatinine, whereas testosterone increases these levels, which can lead to incorrect estimation of glomerular filtration rate, drug dosing, and chronic kidney disease staging. Oestrogen therapy also causes decreased serum calcium, albumin, and alkaline phosphatase concentrations, while testosterone can increase serum triglycerides and decrease high-density lipoproteins (8).

Other potential factors to consider in transgender and gender diverse individuals are listed in the following table.

Potential associated factor	Considerations
Anxiety and depression	Drug-drug interactions with SSRIs, SNRIs and MAOis can precipitate hypotension, arrhythmias, post-operative confusion (9). Monitor closely for signs of toxicity or withdrawal.
Substance Use	Cigarette smoking increases risk of intraoperative pulmonary complications, postoperative cardiovascular complications and sepsis. Chronic alcohol intake increases dose requirements of anaesthetic agents, delays gastric emptying, and is associated with increased post-operative complications.
HIV	Protease inhibitors and non-nucleoside reverse transcriptase inhibitors used for antiretroviral therapy inhibit CYP450 enzymes and impairs metabolism of anaesthetic agents like midazolam and fentanyl (8). Increased risk of coronary artery disease, thromboembolic events, and pulmonary complications
Labour and pregnancy in AFAB individuals	Significant distress associated with vaginal examination and sensation of labour High risk of gender dysphoria Early epidural should be considered if individual wishes to labour.

 

 

 

 

 

 

 

Congratulations! By being aware of transgender issues, you approach your discussion with Stu in a sensitive, respectful manner. Stu recovers from his surgery and leaves the hospital feeling empowered in his own care, and feels comforted and trusting of future healthcare practitioners!

References:

1. Spizzirri G, Eufrásio R, Lima MCP, et al. Proportion of people identified as transgender and non-binary gender in Brazil. Scientific Reports. 2021;11(1). doi:https://doi.org/10.1038/s41598-021-81411-4
2. Main Features – Sex and Gender Diversity in the 2016 Census. Abs.gov.au. Published 2016. Accessed July 8, 2023. https://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/2071.0~2016~Main%20Features~Sex%20and%20Gender%20Diversity%20in%20the%202016%20Census~100#:~:text=A%20further%2013%25%20described%20themselves
3. Kids Health Information: Gender dysphoria. The Royal Children’s Hospital Melbourne. Published September 2020. Accessed July 8, 2023. https://www.rch.org.au/kidsinfo/fact_sheets/Gender_dysphoria/#:~:text=The%20terms%20
4. WC H, PT CK, L G, et al. Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline. Yearbook of Paediatric Endocrinology. Published online September 11, 2018. doi:https://doi.org/10.1530/ey.15.6.3
5. Lennie Y, Leareng K, Evered L. Perioperative considerations for transgender women undergoing routine surgery: a narrative review. British Journal of Anaesthesia. 2020;124(6):702-711. doi:https://doi.org/10.1016/j.bja.2020.01.024
6. Tsen LC, Arthur G, Datta S, Hornstein MD, Bader AM. Estrogen-induced Changes in Protein Binding of Bupivacaine during in Vitro Fertilization . 1997;87(4):879-883. doi:https://doi.org/10.1097/00000542-199710000-00023
7. Australian Product Information Apo-bicalutamide 50 mg (Bicalutamide) Tablets. www.ebs.tga.gov.au. Published March 12, 2019. https://www.ebs.tga.gov.au/ebs/picmi/picmirepository.nsf/pdf?OpenAgent&amp
8. Chinniah S, French JLH, Levy DM. Serotonin and anaesthesia. Continuing Education in Anaesthesia Critical Care & Pain. 2008;8(2):43-45. doi:https://doi.org/10.1093/bjaceaccp/mkn006
9. Tollinche LE, Van Rooyen C, Afonso A, Fischer GW, Yeoh CB. Considerations for Transgender Patients Perioperatively. Anesthesiology Clinics. 2020;38(2):311-326. doi:https://doi.org/10.1016/j.anclin.2020.01.009