Perioperative anaesthetic concerns in transgender patients: Indian perspective.

Medical care of transgender patients is not only legally bound but also ethically required. Globally, 0.5%-0.9% of the adult population exhibits a gender different from their birth sex, but there is a dearth of transgender-friendly hospitals stemming from ignorance to disdain for this marginalised community. With gradually increasing acceptance of the transgender patients in the society, healthcare professionals must gear up to deal with issues specific and unique to this group of population. These concerns remain important to understand for an optimal perioperative care. The medical concerns transcend international boundaries, whereas legal, social, economic and psychological concerns vary from place to place. There is a need for modification of curriculum and training for healthcare personnel to foster sensitivity and empathy in patient dealing, to allow for an unbiased optimal healthcare. Such patients require a thorough assessment in a comfortable environment considering their specific needs. A plan for perioperative care needs to be done and discussed with the patient and the perioperative care team as well. There is scarce literature with regard to perioperative care in the transgender patients and hence requires more research.

INTRODUCTION

Transgender people are those who have gender identity that differs from their assigned stereotyped sex. Transgenders are confronted by socioeconomic marginalisation and a disproportional burden of adverse health outcomes. The stigma in community often prevents these patients from approaching the healthcare professionals. It has also kept the physicians from fully understanding the physical and psychological implications of these patients. As anaesthesiologists, one would be required to provide anaesthesia for routine or emergency surgery, transgender-specific or gender-unrelated surgery, or treat the critically sick in the intensive care unit. There is scarce literature with regard to perioperative care in the transgender patients. This review focuses on the perioperative care of transgender patients, highlighting the unique challenges faced and possible solutions.

METHODS

This narrative review is collated after a structured literature search for including relevant published literature. In the absence of literature specific to perioperative care of transgender, this review was planned for assessing the research question: 'What are the perioperative concerns for management of transgender scheduled for surgical interventions?' The PICOS (Participants, Intervention, Comparisons, Outcomes and Study design) was followed. The authors performed an explorative search from different search engines including PubMed, Embase, Cochrane and Google Scholar for all manuscripts published till July 2018. The search terms for retrieving the manuscripts included transgender OR trans OR LGBTQ AND Anaesthesia OR Perioperative care OR analgesia OR Surgery OR Complications. The assessed manuscripts were screened manually for its relevance for this review. The reference list of the retrieved manuscripts was additionally scrutinised for relevance and for any missing manuscripts. The search based on their bibliography was again ascertained to retrieve any missing relevant manuscripts. In the absence of relevant studies for a particular study design, the assessment of bias, systematic review, or pooled analysis/meta-analysis was not feasible. We included all studies' designs including prospective, retrospective, randomised, nonrandomised, blinded, nonblinded, or cohort studies and even the case reports and case studies.

Of the 164 manuscripts, this review included 32 manuscripts inclusive of all types of published manuscripts as others did not fulfil the 'PICOS' criteria as defined for our research question.

TRANSGENDERS IN INDIA: FACTS AND FIGURES

There are subtextual and direct references to a 'third sex' in the Vedas, ancient Hindu law (Manu Smriti), medicine, linguistics and astrology.[123] British rule introduced the binary/dichotomous model enshrined in the Western community and marginalised/criminalised the third sex.[14] This is set to change fast with the recent judgement by the Honourable Supreme Court quashing the age-old article 377 of the Indian Constitution opening new avenues for social acceptance in India for the LGBTQ (lesbian, gay, bisexual, transgender and queer) community.[5] As per the 2011 census, about 4.9 lakhs of strong transgender community exists in India with a prevalence of 36–69/100,000 across various states of India.[6] This seems lower than the global prevalence (0.5%–0.9%) because of the iceberg phenomenon (more undisclosed cases than documented ones due to the social stigma attached).[78] The transgender activists, however, estimate the numbers to be six to seven times higher.

MEDICAL CONCERNS

Transgender, also known as 'trans', continues to be among the most marginalised in the LGBTQ community. 'Trans' patients have unique medical and mental health needs, facing significant barriers to healthcare, primarily because of discrimination and inadequate insurance coverage. These patients are at especially high risk for harassment, assault or sexual violence in home, school and community settings. Human immunodeficiency virus (HIV) infection is prevalent in transgenders and is reported to be 30 times the national average in India. National HIV prevalence is 0.31% in India, as against the 8.2% prevalence in the Indian transgender community.[9] There is also a higher incidence of drug abuse and psychiatric illness, intimately linked to the chronic stress of societal stigma, discrimination and violence.[10]

The risk of cancer in the transgender population is known to be higher than normal owing to several predisposing factors such as high-dose prolonged unmonitored hormonal therapy for gender affirmation, retained gonads, cigarette smoking and alcoholism, substance abuse, sexually transmitted diseases (STDs), human papilloma virus, and HIV infections.[10] A large number of them require surgical interventions, which at times can be more than one. Thus, transgender patients are vulnerable to medical, surgical and psychiatric illness. In view of the associated comorbidities, detailed perioperative workup is required for the transgender. For this, the treating medical team (anaesthesiologists, surgeons, nursing staff, operating room staff, pain therapists, etc.) must be appropriately trained.

Unfortunately, in India most medical students and residents at present receive little or no training in medical school or residency about caring for the transgender patient. Unfamiliarity with this group of patients can lead to compromised patient interaction and suboptimal healthcare.[1011]

UNDERSTANDING THE CONCERNS

The concerns in transgender patients include legal, social, psychological and medical. While the legal, social and psychological concerns would vary from one community and country to another, the medical concerns are largely the same. The medical concerns are further subdivided into endocrinological, surgical, anatomical and anaesthetic concerns.

Legal concerns

After years of social stigma, prejudice and discrimination, the National Legal Services Authority (NALSA) versus Union of India, landmark judgement (2014) came as a breather.[4] Supreme court directed all state governments to legally recognise transgenders as third genders for educational and employment purposes.[12] Abrogation of section 377 of the IPC in September 2018 has legalised transgenders and will likely lead to increasing visibility, acceptability and more frequent encounters with the 'Rainbow people' in the surgical setting.

Social concerns

As social discourse progresses regarding the health and human rights of all genders and sexualities, 'trans' individuals are presenting to medical and mental health providers in increased numbers. Most trans patients present to the emergency for problems unrelated to their gender identity, but may also present with concerns related to their gender such as pain, depression, suicidality, injury from abuse or assault.[11]

A basic understanding of few terms is imperative to the discussion.

Transgender is usually used for any person whose gender identity and/or gender expression differs from the sex which was assigned as per birth record.[13] The term is commonly used in the Indian community for describing a variety of cross-gender behaviours and identities.[13] The transgender terminology refers its usage as adjective rather than as a noun for any individual[13]

Transsexual terminology has been used more commonly since long worldwide. It remains more specific and applicable clinically as well to the individuals who are being managed with some sort of hormonal therapy and even at times undergo surgical treatment. To modify their body configuration and make them liveable as members of the opposite sex as against the birth-assigned sex. However, this term is generally falling out of favour.

Sex and gender: Sex is not synonymous with gender. While the former refers to physical differentiation as male/female based on external genitalia and internal gonads, the latter stems from psychological self-identification and desire to be identified by others into social categories such as man or woman.[5] Gender is the 'brain sex' of the person. Transgender is the extreme form of gender dysphoria (incongruence between sex and gender).

Psychological concerns

The basic information elicited from every patient starts with a name and sex of the patient to be recorded. This could be quite tricky in the case with transgender patient. If in doubt, the physician should ask how the patient wishes to be addressed. In case a mistake or assumption is made, a simple outright apology is better. As far as sex of the patient is considered, a simple and effective solution could be to ask two different questions, the present gender identity and the sex mentioned in birth record. A third option can also be provided which is to decline to answer. It goes a long way in reassuring the patient that all efforts are directed in providing the best possible medical care without any bias or judgement. The question of privacy during an examination also needs serious thought. A medically indicated examination should be carried out sensitively, in the presence of a chaperone, whose gender must be of the patient's choice and comfort. The patient's biological sex should be known to perform measurements such as creatinine clearance and to prevent teratogenic agents from being given to a transgender or transsexual man who could be or is capable of becoming pregnant. The absence of specific gender assignment creates concerns in many calculations wherein gender needs to be considered for the outcome measurement, for example, Schnider model for target controlled propofol infusion and ideal body weight.

Medical concerns

Sexual realignment practices in transgenders

Physical measures and hormone therapy (HT) generally predate sex reassignment surgery (SRS) in such patients. Physical measures such as tight chest binders may lead to restrictive lung disease in trans-males. Trans-females may resort to silicon injection which may become complicated by infection, silicon migration, granulomas and pneumonitis.[141516171819] HT gives the desired results albeit at the cost of sometimes unacceptable side effects. Oestrogen therapy in trans-females necessitates venous thromboembolism prophylaxis, besides making them prone to migraine and postoperative nausea and vomiting.[1420] There exists a 20 times greater risk of thrombosis in the first 2 years of oestrogen therapy which is compounded in smokers.[21] In trans-males, parenteral testosterone may raise hematocrit to upto 48%, compounding the risk of cerebrovascular accidents and stroke.[22] Liver dysfunction, dyslipidemia, acne and adverse psychological changes may coexist.[212223] Complete withdrawal of HT for prolonged periods (2–4 weeks) before surgery (and its reinitiation postoperatively) should be done in consultation with the endocrinologist since it can have profound effects such as reversal of the masculinising effects, loss of muscle mass and resumption of menses in trans-males.[1415]

Gender confirmation or affirmation surgery

Apart from incidental surgeries for conditions such as appendicectomy and cholecystectomy, transgender may also require various surgical interventions for altering the body appearance so as to reflect the individual gender identity as per choice. Previous terminology includes SRS or sex change operation, but is now considered derogatory. Gender affirmation surgery (GAS) realigns the sex, to conform to the gender which the patient identifies.[24] Patient may also present for revision surgery for complications of GAS (rectovaginal fistula, flap necrosis, prolapsed neovagina, urethral stricture scar revision). A gender certificate should ideally be issued to the patient with operating surgeon, anaesthesiologist, psychiatrist and endocrinologist as signatories after successful completion of GAS.[4]. An algorithm for managing such patients is provided in Figure 1. GAS includes different procedures such as 'top surgery' (breast reconstructive surgeries such as augmentation or removal), 'bottom surgery' (genital reconstructive surgeries to match the appearance of the desired sex) or facial feminisation surgery (to match the appearance of desired gender). Such surgical intervention requires sequence of surgeries for various body parts, and at times a specific surgery is done in multiple steps to attain the desired outcome for belonging to specific gender. However, all individuals may not wish, need or can have surgery for altering their gender identity. Even though most of these procedures are considered 'elective' or 'cosmetic', they may actually be essential for the individual for its gender acceptability and thus require timely surgical intervention.

Figure 1

Algorithm for gender affirmation surgery (GAS)

Standards of care

One cannot overemphasise the importance of documentation (legal photo identity card like passport/Aadhar card) for legal and insurance purposes in these patients.[22] An attendant whose sex is decided by the patient should be present during physical examinations. Connor–Davidson resilience scale is the ability to 'thrive in the face of adversity'. Transgenders in India scored a dismal (59.30 ± 15.03) in the Connor–Davidson resilience scale, which is lower than that of any other population worldwide.[23] Family acceptance, societal acceptance, mainstreaming to the education and employment sectors, and provision of healthcare and social services would bring changes in their lives. Harry Benjamin International Gender Dysphoria Association 'Standards of Care' comprises the following key points:[252627]

Evaluation by one or more mental health professionals for eligibility and readiness criteria is a prerequisite for chest/breast SRS and genital SRS but not for facial feminising surgery or voice pitch elevation surgery. Feminisation surgeries include rhinoplasty, face-lifting, lip enhancement, facial bone reduction, blepharoplasty, breast augmentation, waist liposuction (body contouring), reduction thyroid chondroplasty, body-hair removal, laryngoplasty and skin resurfacing

The plastic surgeon is part of a multidisciplinary team (surgery, gynaecology, urology, endocrinology, community medicine, nursing, psychiatry, psychology) participating in a long-term therapy. He/she must understand the basis for recommendation for SRS (not all persons assigned female gender at birth are women) and co-ordinate with other team members

The surgeon must have specialised competence in SRS

Comprehensive evaluation of the patient's overall health, physical and mental, prior to SRS.

Preoperative assessment

Transgender patient assessment requires holistic assessment, not only routine preoperative assessment like other patients but also many specific history, examination and investigations are deemed necessary for these patients as a part of preoperative assessment [Table 1]. The preanaesthetic evaluation targets patient optimisation through risk reduction and informed consent.[28] Very little evidence-based literature is available on the perioperative care of transgender patients and unfamiliar medical staff only compounds the problem further. The recommendations/suggestions for an optimal care specific to transgender are also not reported.

Table 1

Preoperative assessment

General information	Preferred way to be addressedSex at birthPresent gender identityGive option to decline to answer
Clinical examination	If medically indicatedSensitive and gentleChaperone of gender of patient’s choice
Hormone therapy use	Masculinising or feminising therapyDuration of usePrevious surgeries performed
Laboratory evaluation	Conventional limits may be inaccurateParameters related to sex at birth should be testedPregnancy should be ruled out in appropriate patientsEffects of hormonal therapy should be consideredHigher incidence of HIV in transgender females
Counselling and consenting	Adequate time to be devotedPossibility of need for discontinuation of hormone therapy to be discussedPsychiatric evaluation

Endocrinological concerns

Anaesthesiologists should familiarise with the various hormonal therapy regimens and their implications on perioperative care.[2930] Feminising hormonal therapy includes androgen blockers such as spironolactone, 5-α-reductase inhibitors such as finasteride, and gonadotropin-releasing hormone agonists such as leuprolide and goserelin along with oral, parenteral or transdermal estrogens. Most hormonal therapies entail a lifelong administration, barring serious adverse effects. Patients on this therapy must be screened for thromboembolism and dyslipidemias attributable to estrogens.[31] Patients on oral formulations have been found to be at particularly high risk, so much so that they may need to be discontinued a few weeks before elective surgery.[32] Female-to-male patients on testosterone therapy may have an increased risk for developing liver disease and breast and endometrial cancers.[33] Although discontinuation of hormonal therapy may be warranted in the preoperative period, the surgeon and endocrinologist should collaborate in making a decision as complete withdrawal can have a profound impact on the patient. Common symptoms include mood swings and hot flushes and a longer withdrawal may lead to reversal of the effects.[34] The same amount of deliberation is needed before restarting the therapy postoperatively. Thus, importance of a complete lipid profile, liver function tests, cancer screening and cardiopulmonary workup for transgender patients on hormonal therapy cannot be overemphasised.

Routine laboratory investigations, as indicated by the underlying condition and assessment need to be done. However, the interpretation may not be straightforward due to variable effects of hormonal therapy on some hematologic, general chemistry and special chemistry/endocrine parameters. Some laboratory tests based on biological sex of the patient may need to be ordered, for example, prostate-specific antigen or human chorionic gonadotropin in transgender female and male, respectively.[35] The results may be difficult to interpret in patients during the transition on hormonal therapy. It has been suggested that transitioning transgender patients on hormone replacement therapy for more than 6 months should have their laboratory values compared to that of their cis-counterparts and not their sex assigned at birth, although limited evidence is available to guide the evaluation of laboratory test results in the different stages of transition. Higher incidence of HIV in transgender women must be borne in mind as should the possibility of pregnancy in transgender men.[36] These patients need to be assessed for airway-related issues as well, since many times previous surgeries may have done for voice changes such as laryngoplasty or chondroplasty.

The anaesthesiologist as a perioperative physician should spend appropriate time for psychological preparation, discussion and counselling for perioperative care and needs for allaying all fears and anxieties of the patient as well as the family members. This is particularly important before gender-confirming procedures. All queries must be discussed as professionally as possible and deviations to social and cultural tangents be avoided.

Anaesthetic concerns: Intraoperative management

The anaesthetic plan should be put into place, keeping in consideration all information derived in the preanaesthesia workup. The perioperative staff should be informed of the sensitive nature of the patient's identity, and any patient preferences should be made known. Unnecessary questions and discussions pertaining to the patient's transgender status should be discouraged. All efforts should be made to minimise traffic and rotation of staff in the operating room, especially if the surgical procedure involves exposure of the genitalia or chest area.[37]

Administration of anaesthesia to transgender patients during the intraoperative period should proceed according to standard practice and institutional protocol. Drug interactions with anaesthetic agents need to be assessed and managed accordingly. However, no major interactions occur with anaesthetic drugs used. Patients on oestrogen therapy must be monitored for deep vein thrombosis and thromboembolism. Prophylaxis for the same in the form of anticoagulants and compression stockings should be considered depending on other risk factors such as smoking, coagulopathies and duration and nature of surgery.[19]

Some anatomical considerations may be of interest in this group of patients. The routine procedure of urinary catheterisation can become challenging due to previous gender-confirming surgery involving the urethra, such as vaginoplasty, phalloplasty or metoidioplasty with urethral lengthening. Airway management may be affected by previous laryngoplasty or chondroplasty to alter the voice pitch, which may result in vocal cord damage, tracheal stenosis or even perforation in transgender women.[38] Some transgender men may be using breast binders or chest wraps, which may be advisable to remove to prevent restrictive respiratory compromise.[14] A sensitive and detailed discussion with the patient and family ought to be completed in the preoperative period itself, to ensure the safety and dignity of the patient [Table 2].

Table 2

Intraoperative management

Special instructions	Minimum staff trafficStaff to avoid unnecessary questions or discussionsUniversal precautions: if HIV-positive
Anaesthesia management	Standard monitoring, indicated by surgical procedureStandard anaesthesia techniqueDifficult airway cart
Intraoperative concerns	A steroid bolus 100 mg hydrocortisone: avoid steroid withdrawal syndromeDeep Venous Thrombosis prophylaxis and monitoring for thromboembolismProblematic catheterisation in case of gender affirming urological surgeryAirway changes after procedures to change voice pitchBreast binders and chest wraps to be removed

Postoperative management

The postoperative period remains a difficult time for the transgender patients to tide over, especially after gender-confirming surgery. Although the procedure undertaken may have been entirely elective, patients commonly encounter anxiety, fear, depression and even regret. This could be worsened by awkward or negative interactions with healthcare providers. An optimal analgesic regimen for transgenders and the interaction for various analgesia regimens for intravenous analgesics and nerve blocks have not been reported in literature. As previously emphasised, sensitivity training of staff is essential in fostering feelings of respect and trust between the transgender patient and healthcare provider. All sensitive information with respect to gender identity, preferred name or pronoun to be used should be included in the staff handover to avoid repeated questioning from the patient. A team approach involving mental health, social work and spiritual care to address all aspects of the patient's discomfort is preferable. Community and social work support should also be implemented early in the postoperative period to ease the process of discharge and transition to recovery.[14]

CONCLUSION

Following the recent Supreme Court judgement, the acceptability of transgenders will increase. Transgenders require special consideration in the perioperative care because of distinctive health risks, specific healthcare needs and healthcare disparities. Also, they are at risk for having chronic diseases, mental health problems, depression, STDs and domestic violence and may thus require management accordingly. Physical measures with psychiatrist analysis for 18 months followed by hormonal therapy for 12 months, followed by sexual reassignment surgery in that order is the specific timeline followed by transgenders in their transition to the gender they identify with. Their perioperative care requires multidisciplinary involvement including endocrinology, anaesthesiology, psychotherapy, psychiatry and social worker. Also, more evidence is required for recommendations related to perioperative care in the transgender.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.