Perioperative considerations for person-centered gender affirming surgery

Abstract

With more than 1 million people identifying as transgender in the United States alone, the likelihood of encountering a transgender patient and their family of choice in the perioperative setting is very high. A lack of data exists to equitably inform transgender-specific issues, as well as the associated morbidity during the transgender reassignment perioperative period. Anaesthesiologists should actively acquire the knowledge and skills needed to inclusively and respectfully manage these patients and be aware of their unique physiological and psychosocial needs. The pre-operative approach includes a detailed history, focusing on the patients cross-sex hormone treatment (CSHT) regimen and associated medical conditions. An in-depth understanding of commonly used hormones such as estrogen and testosterone and their effect in the perioperative periods is essential. The physical examination should be relevant to the anatomy that is currently present while taking into consideration feminising and masculinising procedures (e.g., genioplasty, thyroid cartilage augmentation), how these interventions alter the anatomy, and potential airway complications. Laboratory results should be interpreted with care – and with expert assistance if needed - as hormone therapy might affect reference values. In addition, risk assessment tools should be used with caution since they often include sex in their scoring system but do not account for the use of CSHT. Intraoperative considerations include urethral catheter placement, drug dosing, and drug interactions that are commonly encountered in the transgender patient. Special attention should be taken in transgender females who have undergone vocal feminization, as case reports have described unexpected difficult airway management. A multimodal approach, which includes regional blocks and attention to pre-existing chronic pain conditions, should be employed as part of the post-operative pain management plan. The post-operative nausea and vomiting risk has not yet been established in this population, requiring appropriate anti-emetic prophylaxis. Despite societal advances that improve transgender health, the medical community still lacks empirical evidence to effectively mitigate the distinctive challenges confronted by this at-risk population.

Introduction

One in every 250 adults, or almost 1 million people identify as transgender in the United States alone.^1,2 These estimates are likely conservative due to the stigma attached to identifying as transgender and the paucity of research that has attempted to study phenomena relevant to the transgender population. In fact, the National Academy of Sciences recently put forth several recommendations to improve funding and infrastructure that supports accurate, representative sexual and gender diverse research with the goal of informing high-quality, evidence-based interventions.³

“Transgender” is often poorly understood and misappropriated. The umbrella term “transgender” is generally used to describe discordance between the cultural expectations associated with the anatomical sex assigned at birth and the gender a person choose to identify with and/or express⁴. Some transgender people may experience gender dysphoria, which is the clinically significant impairment of social, occupational, or other important areas of functioning caused by this sex assignment – gender identity/expression discrepancy.⁵

The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association who have established internationally accepted standards of care for the treatment of gender dysphoria, including gender affirming therapies.⁶ Gender affirming therapies refer to behavioural modification, psychotherapy, cross-sex hormone therapy (CSHT), and surgical therapies (see table 1).

Table 1.

Gender affirming surgeries

Transgender female	Mammoplasty (top surgery) Facial feminization Voice feminization Thyroid cartilage reduction Gluteal reconstruction Penectomy Orchiectomy Vaginoplasty/clitiroplasty/labiaplasty
Transgender male	Chest wall reconstruction (top surgery) Fascial masculinization Voice masculinization Thyroid cartilage augmentation Hysterectomy/oophorectomy Vaginectomy Metoidioplasty Phalloplasty/scrotoplasty Penile or testicular prosthesis

Adapted from Pan S, Honig SC. Gender-Affirming Surgery: Current Concepts. Curr Urol Rep. 2018;19(8)

The American Society for Plastic Surgeons reported that gender affirming surgeries were among the most rapidly increasing procedures between 2016 to 2017, with a 289% increase for transgender men (e.g., a person who identifies/expresses as a man but was assigned anatomically female at birth) and a 41% increase for transgender women (e.g., a person who identifies/expresses as a woman but was assigned anatomically male at birth).⁷ The 2015 US Transgender Survey showed that 25% of transgender responders had already undergone 1 or more gender-affirming surgeries.⁸

With legal provisions like Section 1557 of the Affordable Care Act⁹ and cultural shifts enhancing protections and inclusion for the transgender population, the likelihood of encountering a transgender patient in the perioperative setting is very high¹⁰. Interprofessional anesthesiologists, including anesthesia teams, should be equipped with and actively acquire the knowledge and skills to safely and equitably care for transgender patients during gender affirming perioperative periods^11,12. This article aims to outline the potential pre-, intra-, and postoperative considerations for gender affirming procedures, among transgender adults

Pre-operative

A number of study findings have shown high levels of transgender discrimination throughout the care continuum, suggesting health system engagement may be a potentially marginalizing and traumatizing experience for this population. .^{13,14,15,16,17} It is important to create a clinical and interpersonal environment where the patient and their family of choice feels respected and included throughout the design and implementation of their plan of care.

The patient’s self-identified name and pronouns should be documented and used at all times (see table 2). All staff across the patient care experience should be aware of transgender terminology and sensitivity. Bathroom policies should be clearly defined as either being gender-neutral or allowing the patient to choose bathrooms based on their own preference. Patients should be roomed according to their gender identity or given a private room if available. In order to co-create truly inclusive patient care milieus, organizations must implement guidelines that reflect published patient bills of rights for sexual and gender diverse populations, such as those published by the Human Rights Campaign (https://healthcarebillofrights.org/Assets/Documents/Partners/BOR/hrc.pdf) or the New York City Department of Health (https://www1.nyc.gov/assets/doh/downloads/pdf/ah/lgbtq-bor-wallet.pdf).

Table 2.

Gender pronouns

Binary	He/him/himself She/her/herself
Non-binary	They/them/themselves Ze/zir/zirself

Adapted from Gender Neutral Pronouns. USC LGBTQ+ student center

History taking

In most cases, the initial medical treatment of gender dysphoria involves the use of cross-sex hormone therapy (CSHT) and/or medications that block the effects of endogenous hormones^18,19 Transgender individuals need the same range of surgical care as the majority cisgender (anatomical sex at birth and gender identity/expression concordant) population but limited research exists on the perioperative morbidity associated with CSHT. As part of the pre-operative assessment, it is critical to ascertain the patient’s treatment regimen (see table 3) and be aware of the associated side effects and pharmacological interactions.

Table 3.

Hormone Therapy

Transgender females	Transgender males
Estrogen  Oral: Estradiol  Transdermal: Estradiol transdermal patch  Parenteral: Estradiol valerate or cypionate	Testosterone  Parenteral: Testosterone enanthate or cypionate  Transdermal: Testosterone gel, patch
Anti-androgens  Spironolactone  Cypterone acetate  Finasteride  Dutasteride
GnRH agonists

Adapted from Hembree WC, Cohen-Kettenis PT, Gooren L, et al. Endocrine treatment of gender-dysphoric/ gender-incongruent persons: An endocrine society*clinical practice guideline. J Clin Endocrinol Metab. 2017;102(11):3869–3903

Commonly utilised hormone therapies by transgender women include oral estradiol (17-beta estradiol), transdermal estradiol, parenteral estradiol valerate or cypionate^18–20. They are often combined with anti-androgens such as spironolactone, cypterone acetate, finasteride, and dutasteride in order to produce the desired physical changes such as breast growth, fat redistribution, and decreased facial and body hair²⁰ Commonly used CSHT in transgender men include the delivery of testosterone via transdermal (e.g., gel, cream, or patch), subcutaneous, or intramuscular administration routes.

The primary CSHT health concern relevant to surgical care is the potentially elevated risk of venous thromboembolism (VTE), and the subsequent risk of pulmonary embolism, myocardial infarction, and stroke.

Estrogen

Estradiol is generally delivered to transgender women via a transdermal patch, oral or sublingual tablet, or injection of a conjugated ester.⁶ The use of ethinyl estradiol is not recommended due to its associated thrombotic risk. This risk has been well established in the gynaecologic literature, specifically in studies of combined oral contraceptives (COCs) and postmenopausal hormone regimens in the cisgender woman.²¹ Estrogen increases the level of fibrinogen, factor VIII, von Willebrand factor, factor VII, factor X, and prothrombin increase while the level of protein S decreases.²²

However, the nuances of VTE risk in transgender individuals using hormone therapy are poorly understood. Studies have attempted to examine whether use of oral contraceptives and or hormone therapy in transgender woman increase the risk of thrombosis, and results have been mixed. For example, the risk seems to increase with the historic use of ethinyl estradiol, whereas small studies demonstrate a lower risk of VTE with 17-beta estradiol.^23,24 Transdermal estrogen has been reported to have the least thrombogenic profile in transgender woman, although there are a lack of comparative formulation studies.^25,26

The lack of evidence to support routine discontinuation of CSHT prior to undergoing planned surgeries leads to inconsistencies in general practice. The WPATH advise to continue estrogen therapy before and after surgical procedures in transgender women who lack specific risk factors such as smoking, family history, or the use of synthetic estrogens. ²⁷

Stopping estrogen therapy in the perioperative setting should always be discussed with the patient and decided in collaboration with the prescribing endocrinologist. An acceptable time frame for estrogen discontinuation is typically 2 – 4 weeks pre-procedure. Expected physiological and psychological withdrawal symptoms include fatigue, anxiety, depression, autonomic hyperactivity, and decreased seizure threshold.²⁸

Cyproterone Acetate

Cyproterone acetate (CPA) is a commonly used anti-androgen agent in Europe and Canada, however it is not currently approved for use in the United States. CPA has been associated with adrenal suppression, elevation of liver enzymes, and, when in combination with estrogen, increased thromboembolic events²⁹. Apart from its anti-androgen effect, CPA also has progestogenic activity which stimulates ventilatory action and increases the sensitivity of the respiratory centre to carbon dioxide. This in turn can lead to dyspnea and associated respiratory alkalosis, usually observed in higher doses in the context of prostate cancer treatment. ^30,31 Elevation in liver enzymes, as well as fulminant hepatic failure, have also been observed in higher doses.³² However Fung and colleagues showed that halving the traditional dose of CPA in transgender women to 25mg daily was as effective at testosterone suppression in the physiologic female using the traditional 50mg dose and thus might decrease the burden of adverse events.^33,34

Spironolactone

Spironolactone acts as a moderate anti-androgen and is a component of feminizing hormone therapy for transgender women ³⁵ Spironolactone is a potent mineralocorticoid receptor antagonist that blocks the effect of aldosterone and exerts its primary function as an antihypertensive and diuretic³⁴ The perioperative morbidity and mortality associated with spironolactone has been extensively studied in the cisgender population with one prospective cohort study finding no increase in atrial fibrillation after cardiac surgery for patients taking the medication³⁶ and a placebo-controlled randomized clinical trial showing no heightened risk of kidney injury for those prescribed the medication prior to surgery. ³⁷ However the anesthesiologist should be aware of its possible side effects, including hypotension and hyperkalaemia. Discontinuation in the preoperative setting can be decided case by case.

Testosterone

Despite a perceived negative impact on a number of risk factors, such as a decrease in high-density lipoprotein cholesterol (HDL) and increases in hematocrit, triglycerides, low-density lipoprotein cholesterol levels (LDL), inflammation markers (C-reactive protein), and a minimal rise in systolic blood pressure, the use of testosterone has not been associated with increases in morbidity or mortality³⁸

Evidence suggests there is no need to routinely discontinue testosterone treatment in transgender men prior to scheduled or elective surgery. Testosterone can be aromatized to oestradiol, which theoretically could increase the clotting risk. However, a recent systematic review did not demonstrate any association of increased VTE complications after surgery with perioperative testosterone use^18,39,40

A small cohort found that transgender patients taking testosterone hormone therapy were more likely to experience hematoma after chest reconstruction surgery, but this risk was not statistically significant.³⁹

Associated medical conditions and priorities

HIV

There is a high prevalence of human immunodeficiency virus (HIV) in the transgender community, with infection rates estimated at 14% among transgender women.⁴¹ Perioperative risks linked to HIV infection include hepatic and renal dysfunction, coronary artery disease, pulmonary arterial hypertension and cardiac abnormalities, respiratory complications, drug allergies, and hematologic abnormalities.⁴² Some antiretroviral therapy medications, specifically the protease inhibitors (e.g., ritonavir) and nonnucleoside reverse transcriptase inhibitors (e.g., nevirapine), are primarily metabolized by cytochrome P-450 enzymes. The anesthesiologist needs to be aware that these drugs may have significant interactions with sedatives, hypnotics, anxiolytics, and antibiotics⁴³

Diabetes Mellitus

In one cross-sectional study, researchers found that both trans men and women had a higher prevalence of type 2 diabetes than a control group of cisgender men and women.⁴⁴ Transgender people were also shown to have several modifiable factors that contribute to diabetes complications, specifically high triglycerides and high-density lipoprotein cholesterol.⁴⁵

Psychiatric and psychological considerations

Transgender patients continue to face significant levels of discrimination, stigma, and physical violence throughout society that may contribute to increased psychiatric and psychological sequelae. Data suggest there is a higher incidence of mood and anxiety disorders than compared to cisgender counterparts, with suicide remaining as one of the leading causes of death.^46,47 Pharmacological therapies and potential psychoactive drug interactions should be evaluated by the anesthesiologist.⁴⁸ Careful consideration should be given to patients on tricyclic antidepressants (e.g., amitriptyline), mood stabilizers (e.g., lithium), and selective serotonin reuptake inhibitors (e.g., escitalopram).

Compounding the high burden of psychiatric disease among the transgender population are higher rates of alcohol, cannabis, cocaine, amphetamine, methamphetamine, and opiate use compared to the general population.⁴⁹ Both acute intoxication and chronic substance use disorder present challenges for anesthetic management during and after an operation.

Physical examination

A focused physical examination must be performed as part of the pre-operative assessment. The examination should be relevant to the anatomy that is present, regardless of gender presentation, and without assumptions as to the anatomy or identity of the patient.

The anesthesiologist should be familiar with the range of cosmetic feminization and masculinization procedures and how they affect the anatomy relative to the airway. These changes may mislead or make a proper evaluation more challenging due to a change in face shape and structure (see table 4)

Table 4.

Fascial feminization and masculinization procedures

	Feminization	Masculinization
Upper third	Forehead contouring, brow lift, scalp advancement, supraorbital ridge contouring	Forehead augmentation
Middle third	Zygoma osteotomies, rhinoplasty	Maxillary augmentation, rhinoplasty
Lower third	Genioplasty, mandibular angle reduction, chondroplasty	Mandibular angle augmentation, genioplasty, thyroid cartilage augmentation

Adapted from Morrison SD, Vyas KS, Motakef S, et al. Facial Feminization. Plast Reconstr Surg. 2016;137(6):1759–1770 and Sayegh F, Ludwig DC, Ascha M, et al. Facial Masculinization Surgery and its Role in the Treatment of Gender Dysphoria. J Craniofac Surg. 2019;30(5):1339–1346.

Facial feminization

The height of the female jaw is typically 20% shorter than in males. Mandibular angle reduction and a reduction in chin width and height are therefore performed as part of feminizing the lower face (Figure 1). Procedures like T-ostomy of the chin can lead to scar tissue in this area, may reduce movement of the mandible, and may make mask ventilation challenging.⁵² (Figure 2) These procedures will result in a crowded oropharynx as well as shorter thyromental distance with a reduced mandibular space, which makes the axis of the larynx less likely to line up with the pharyngeal axis, thus increasing the difficulty of tracheal intubation

Figure 1A:

Pre mandibular angle reduction. From 2pass.clinic

Figure 2A:

Pre genioplasty. From 2pass.clinic

A prominent thyroid cartilage, colloquially referred to as an ‘Adam’s apple’ contributes to the feeling of dysphoria in transgender woman. The surgical technique ofchondrolaryngoplasty involves reducing or shaving the thyroid cartilage prominence, thereby minimizing the appearance of this male physical characteristic.⁵³ (Figure 3) Estimating the correct thyromental distance in these patient may be challenging. Scar tissue from these procedures can also lead to problems with mask ventilation, tracheal intubation, and more specifically, identifying and puncturing the cricothyroid membrane in an emergency.

Figure 3A:

Pre tracheal shave. From 2pass.clinic

Vocal feminization

The vocal feminizing process can be divided into non-surgical feminization and surgical feminization. The surgical approach can further be divided into three categories: 1) elongating the vocal cords, 2) reducing the vocal mass and length, and 3) procedures to increase tension by producing scars on the vocal folds. These procedures are relevant to the anesthesiologist as they pose challenges to airway management

• Cricothyroid approximation is an open surgical procedure whereby the distance of the cricothyroid distance is reduced by 8–10mm, effectively removing the entire cricothyroid membrane and space.^54,55 This results in elongation and increased tension of the vocal folds, thereby limiting the voice to the upper range.

• Feminization laryngoplasty is a procedure whereby the surgeon removes the anterior thyroid cartilage, collapsing the diameter of the larynx as well as shortening and tensioning the vocal folds to raise vocal pitch.⁵⁶

• Laser reduction glottoplasty is a technique that modifies the density of the vocal folds through CO2 laser ablation⁵⁷

• Anterior commissure formation is an endoscopic de-epithelialization procedure of the anterior commissure with a CO2 laser and suturing of the anterior cords. This will ultimately lead to vocal cord scar formation and increased tension on the cords.⁵⁸

Facial masculinization

Transgender males also seek surgical interventions to transform the feminine features of their face to appear more masculine. Masculinization of the thyroid cartilage is achieved by increasing its size using a graft of rib cartilage. Estimating an accurate thyromental distance might be challenging and scar tissue from these procedures might lead to mask ventilation and intubation problems, as well as difficulty identifying and puncturing the cricothyroid membrane during an airway emergency.⁵² Mandible angle recontouring and genioplasty are well described procedures whereby bony architecture of the face is augmented with surgical implants or fat transfers. ⁵⁹

Chest binding

As part of the initial assessment, it is important to note whether the patient practices chest binding. Chest binding describes a process where transgender individuals use a range of materials or techniques to flatten chest tissue and reduce the visibility of female breast anatomy. Chest binding is associated with a wide range of complications, such as chest and back pain, rib bruising and fractures, shortness of breath, overheating, and skin damage.⁶⁰ Transgender males who habitually wear chest binders were found to have abnormal baseline lung function with an abnormally high FEV1/FVC, lower peak expiratory flow values, and a significant reduction in expiratory vital capacities, both SVC and FVC.⁶¹

Perioperative risk assessment

Preoperative cardiovascular risk assessment requires a focused history and physical examination. Risk models have been designed to estimate patients’ perioperative risk, which often include sex in their scoring system (as opposed to gender sensitive variations) but do not account for the use of CSHT. The male sex usually scores higher when these tools are used and there is a significant chance of underestimating the risk in transgender women if the tool for female sex is improperly utilized.

A recent cross-sectional study showed that transgender men have four times higher odds of having a myocardial infarction when compared with cisgender women and 2-fold compared to cisgender men⁶². Transgender women had an increase in the odds of having myocardial infarction compared with cisgender women but not compared to cisgender men.⁶² Multiple factors including CSHT, increased social stressors, substance abuse, and increased stress levels could play a role⁶³

Examples of commonly used perioperative risk calculating tools that incorporate sex but fail to address CSHT include the Revised Cardiac Risk Index (RCRI), American College of Surgeons National Surgery Quality Improvement Program (ACS NSQIP), STOP-bang score for obstructive sleep apnoea and CHADS2-Vasc.^64–66

Mixed evidence exists pertaining to CHST and perioperative risk of VTE. Factors such as drug form, dose, route and duration all impact the overall risk as previously discussed. According to Guidelines for the Primary Care of Transgender and Gender Nonbinary People and a JAMA surgery review there is no evidence to suggest that transgender patients who lack specific risk factors (e.g., smoking, personal or family history, excessive doses or use of synthetic estrogens) must cease CSHT, especially estrogen therapy, before and after surgical procedures in the setting of appropriate use of thromboprophylaxis (e.g., heparin, compression devices).^18,67 Some surgeons however still prefer stopping CSHT 5 weeks before major surgery and resuming after full physical mobilization is achieved.⁶⁸

Additional testing

Appropriate laboratory testing is an important process in the preprocedural preparation of the patient. These investigations are helpful to stratify risk, direct anesthetic choices, and guide postoperative management. Anesthesiologists should be aware of the expected changes on a blood chemistry panel in transgender patients on CSHT (see table 5).

Table 5.

Blood chemistry changes

	Transgender Woman on CSHT	Transgender Man on CSHT
Increased	Red blood cell count Hemoglobin concentration Hematocrit Creatinine Triglycerides	Red blood cell count Hemoglobin concentration Hematocrit Creatinine Alkaline phosphate Aspartate aminotransferase Alanine aminotransferase Triglycerides
Decreased	Calcium Albumin Alkaline phosphate	High-density lipoprotein

Adapted from SoRelle JA, Jiao R, Gao E, et al. Impact of Hormone Therapy on Laboratory Values in Transgender Patients. Clin Chem 2019;65(1):174

Research suggests transgender patients on CSHT for longer than 6 months should have their laboratory values compared to the reference ranges for the gender counterparts with which they identify rather than with those of their sex assigned at birth⁶⁹ There is clearly a need for new and revised biochemistry reference values for transgender patients. In the interim the UCSF Transgender Care and Treatment Guidelines have created tables as tools for health care providers to interpret chemistry levels (see table 6). ⁶⁷

Table 6.

Interpreting selected laboratory tests in transgender population using hormone therapy (HT)

	Transgender men using masculinizing HT		Transgender women using feminizing CSHT
Laboratory measure	Lower limit of normal	Upper limit of normal	Lower limit of normal	Upper limit of normal
Creatinine	Not defined	Male value	Not defined	Male value
Hemoglobin/hematocrit	Male valuea	Male value	Female value	Male value

^aIf menstruating regularly, consider using female lower limit of normal.

Adapted from UCSF Transgender Care, Department of Family and Community Medicine, University of California San Francisco. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People; 2nd edition. Overview of masculinizing hormone therapy. Deutsch MB, ed. June 2016. Available at transcare.ucsf.edu/guidelines; with permission.

Intra-operative

Anatomic considerations

Gender affirming surgery involving the urethra (e.g., vaginoplasty, phalloplasty, or metoidioplasty with urethral lengthening) might pose catherization problems. Urethral catherization in transgender females can be accomplished by using a coude catheter that is angled cephalad just below the neoclitoris. Small calibre catheters (14 or 16 Fr) should be used in transgender males with a low threshold to consult urology for assistance.¹

Drug dosing

The total body fat increases in transgender females and decreases in transgender males during CSHT.⁷⁰ The fat redistribution may influence the volume of distribution of fat-soluble drugs but drug modelling data is lacking for this population. These changes will also affect the ideal body weight (IBW) calculation as it based on biological sex and does not take into account CSHT.⁷¹

The Schneider model for propofol infusion and the Minto model for remifentanil administration both depend on sex in calculating the ideal body weight.^72,73 To our knowledge, adjustments in anesthesia delivery modules for transgender patients on CSHT is absent in the literature.

Drug interactions

Several drug interactions with estrogen have been documented but the clinical significance in the transgender population still needs to be evaluated. Estrogen may affect neuromuscular blockade by decreasing pseudocholinesterase activity and prolonging muscle paralysis from succinylcholine.⁷⁴ Sugammadex has also been shown to bind to estrogen, potentially decreasing the effectiveness of the hormones in the post-operative period. ^75,76 Estrogen, in doses associated with in vitro fertilization, can cause a decrease in albumin and alpha1-acid glycoprotein. This reduction may lead to an increased free fraction of highly protein bound drugs like bupivacaine.⁷⁷

Careful attention should be paid to the significant interactions between psychoactive and antiretroviral medications.

Airway

Cosmetic and vocal gender affirming procedures can result in vocal cord damage, reduction of the tracheal lumen, or tracheal stenosis. These pose a significant challenge to airway management and must be considered before the patient enters the operating room.

Special attention should be taken with transgender females who have undergone vocal feminization as case reports have described unexpected difficult airway management.⁵² The anterior commissure web formation approach may lead to a smaller glottic opening and a narrower diameter endo-tracheal tube might be needed.⁷⁸ (Figure 4) The cricothyroid approximation approach may effectively remove the entire cricothyroid membrane and space, which is important to note in the setting of a surgical airway. Feminizing laryngoplasty can also reduce the size of the glottic opening and cause anterior neck scar formation which may lead to intubation difficulty and problems in identifying and puncturing the cricothyroid membrane during emergencies.

Figure 4:

Wendlers glottoplasty/anterior commisute web formation. From Brown, S.K., Chang, J., Hu, S., Sivakumar, G., Sataluri, M., Goldberg, L. and Courey, M.S. (2021), Addition of Wendler Glottoplasty to Voice Therapy Improves Trans Female Voice Outcomes. The Laryngoscope, 131: 1588–1593.

Laryngeal mask airway (LMA) use has been proposed as an alternative to endotracheal intubation in chondrolaryngoplasty, as it allows advancement of the endoscope through the LMA until the anterior commissure becomes visible for marking. Local anesthesia is also an option in the cooperative patient.⁷⁹ Laryngospasm, a known complication from vocal cord irritation, has been described with this approach.⁷⁹ Furthermore, with a lack of complete airway protection with LMA use, the anesthesiologist should be both vigilant and comfortable in managing a potential emergency.

Post-operative

Pain

Contributing elements to postoperative and chronic pain include psychological factors, such as depression, fear, and anxiety, and medical factors, such as hormone-induced osteoporosis, previous surgeries, and an impaired immune system⁸⁰ Pain should be managed aggressively throughout all stages of the perioperative period using multimodal analgesic techniques. Timely attention should be given to the effective and ethical management of pre-operative chronic malignant and non-malignant pain conditions and syndromes that were previously treated with evidence-based analgesic regimens, including the use of strong opioids (e.g., morphine) and extended/immediate release combination opioid therapies^81,82,83,84. Pain and palliative care specialists should be consulted where appropriate to assist in managing and titrating pain needs throughout the post-operative and rehabilitative phases.

Several regional approaches have been described for post-operative pain management in gender affirming surgeries. Research has shown that the combined use of general and epidural anesthesia in penile inversion vaginoplasty in transgender woman led to a decrease in opioid consumption.⁸⁵

The use of the erector spinae plane block (ESPB) for pelvic gender affirming surgeries has also been described in the literature. In a case study, an ESPB was successfully used for a penectomy, bilateral orchiectomy and vaginoplasty as part of a multimodal pain regimen.⁸⁶The sacral ESPB offers an alternative to neuraxial or caudal block to provide analgesia for gender affirming surgeries involving the pelvis.

Post-operative nausea and vomiting

Post-operative nausea and vomiting (PONV) are related to several factors such as age, method of anesthesia, type of surgery, smoking history, and sex assigned at birth.⁸⁷ The Apfel score is a commonly used screening tool for PONV, giving an extra point for female sex – a mechanism possibly related to increased baseline levels of estrogen.⁸⁸ Risks have not yet been empirically documented among the transgender population and further research will help with risk stratification. Evidence-based antiemetic prophylaxis should be administered.

Cultural humility to guide person-centered gender affirming care

Many of our clinical recommendations throughout this article have focused on the science of “doing” anesthesia care in the transgender gender affirming surgical context, such as physical examination, medical management, and surgical priorities. However, to assure safe environments where transgender patients and their families of choice feel respected and welcome, all members of the health team – from admission to the operating room – must adopt an inclusive way of “being”. Cultural competence may represent an unachievable proficiency or end-point in meeting cultural needs. In fact, the idea of becoming “competent” in meeting cultural needs is a farce as culture is a multi-layered and complex construct.

Cultural humility is an iterative and circular approach to patient care that promotes: 1) lifelong self-evaluation and self-critique; 2) dismantling power imbalances between anesthesiologist and care recipient; and 3) fostering mutually beneficial and non-paternalistic partnerships with communities being served⁸⁹. Cultural humility invites particular attributes of openness, self-awareness, egolessness, supportive interactions, and self-reflection⁹⁰. This shift toward cultural humility is the premise for dismantling marginalizing health systems and re-humanizing the care experience for transgender patients, as well as other historically underrepresented and at-risk groups^91,92. A first step is to identify one’s implicit biases (https://implicit.harvard.edu/implicit/index.jsp), reflect on how those biases translate into inequitable clinical practices, and then strategically interrupt the narrative.

Anesthesiologists provide vital oversight during a vulnerable period when a patient is unable to advocate for self. Yes, gender affirming surgery carries with it the implications of a physical intervention. But for the patient having surgery, it is also a seminal life event that will inform countless outcomes related to personal identity, psychosocial acceptance, validation, and self-development. Cultural humility can equip anesthesiologists and all clinical staff with the skills needed to meet transgender patients “where they are” in all perioperative stages to affirm the patient experience and acknowledge the challenges inherent to gender affirming surgery.

Conclusion/Summary

The provision of equitable and inclusive healthcare environments for transgender patients and their families of choice requires enhanced medical knowledge but also a commitment to person-centered care practices. It is imperative that anesthesia teams understand how to provide respectful care for this population in the perioperative context. Familiarity with commonly identified medical and psychosocial needs among transgender patients, with an emphasis on gender affirming procedures and safe hormone therapy prescribing, must guide the personal history and physical examination. Future efforts must include dedicated research addressing transgender specific issues in the perioperative period, such as formulating nationally coherent guidelines, further understanding of the perioperative morbidity associated with CSHT, and establishing accepted reference values that are applicable to transgender patients. A thoughtful, person-centered approach throughout the trajectory of the perioperative period is key to the successful, safe, and inclusive management of the transgender patient undergoing gender affirming surgery.

Figure 1B.

Post mandibular angle reduction. From 2pass.clinic

Figure 2B:

Post genioplasty. From 2pass.clinic

Figure 3B:

Post tracheal shave. From 2pass.clinic

Key points.

• Preoperative: Healthcare facilities should be safe and accommodating while prioritizing patient-identified pronoun use, inclusive environments, and welcoming policies at service and organizational levels. History and physical examination should evaluate cross-sex hormone treatment (CSHT) regimens and previous gender affirming procedures.

• Risk assessment: Risk assessment tools should be used with caution as these often include sex in their scoring system but do not account for the use of CSHT. Interpreting selected laboratory results may also differ in patients on CSHT.

• Intraoperative: Considerations include urethral catheter placement, drug dosing adjustments, and possible pharmacological interactions. Gender affirming procedures may alter the airway anatomy and pose a significant challenge to airway management.

• Postoperative: Multimodal analgesic techniques, including regional blocks and consideration of pre-existing pain conditions or syndromes, should be used as part of post-operative pain management.