Peri-operative care of transgender and gender-diverse individuals: New guidance for clinicians and departments

New guidance on peri-operative care of transgender and gender-diverse individuals is published in Anaesthesia to guide best practice to ensure the safety and dignity of transgender and gender-diverse people in the peri-operative period. The guidance has been produced by a working group of experts including Dr. Stuart Edwardson, Royal Infirmary of Edinburgh, Edinburgh, UK; and Dr. Luke Flower, Victor Philip Dahdaleh Heart and Lung Research Institute, Cambridge, UK, and colleagues.

The number of people openly identifying as transgender and/or gender diverse has increased significantly over the past decade, most likely as a result of emerging clarity and comfort with open expression. Census estimates from 2021 identified 262,000 people living in the UK identifying with a gender that does not correspond with that assigned at birth. It is worth noting that this is a lower estimate than others, most likely due to hesitation of people to disclose.

Around 50% of transgender and gender-diverse people are currently undergoing some form of medical treatment for gender affirmation (whether this is hormonal therapy, surgical affirmation or both), and a further 25% are not currently accessing gender-affirming medical interventions but wish to. Many aspects of these interventions provide specific and important considerations for the anesthetist in the peri-operative period.

The authors say, "Transgender and gender-diverse people comprise a significant and varied minority with specific health care needs that are often both poorly misunderstood and met. It is our collective responsibility for this inequity to be addressed.

"Transgender and gender-diverse people, in addition to some specific needs, experience the same health problems as everyone else and will therefore present to all services, whether specialist or not. This guideline sets out a structured explanation of current evidence and practicalities to be considered for any anesthetist looking after a transgender and gender-diverse patient in any scenario or area of the hospital."

They add that the new guidance is necessary as there is currently no existing guidance covering the scope and focus of this document.

The working group's key recommendations

1. The patient's preferred name and pronouns should be confirmed and used at all times. This is an important way of showing respect and decreasing the risk of gender dysphoria.
2. There should be a process in place whereby a patient can privately and safely disclose both their sex at birth and gender as part of pre-operative assessment. Digital pre-assessment questionnaires can provide this in an elective setting.
3. All forms of social, medical and surgical gender affirmation should be identified at pre-operative assessment, and sensitive explanations given to the patient for the purposes of inquiring. Anesthetists should be aware that many aspects of gender-affirming care may not be present on a patient's health record (including gender-affirming surgical procedures).
4. A pre-operative pregnancy test should be offered to all patients who have a uterus and ovarian tissue between the ages of 12 and 55 years, regardless of the use of contraception.
5. All specific peri-operative considerations for transgender and gender-diverse patients, including name and pronouns, should be communicated with the team at the surgical brief. Transgender status need only be shared with the patient's consent and if it is deemed important for the safety of their care. It should be given the same level of confidentiality as any other sensitive personal information.
6. Chest binders should ideally be removed, with the patient's consent, before anesthetic intervention.
7. Hormone therapy should be continued throughout the peri-operative period unless there are specific contraindications. Patients should be counseled on the risks and benefits of this with the aim of making a shared decision.
8. Transgender and gender-diverse patients should be cared for in an environment that respects their gender identity. In some circumstances, this may involve providing a single room.
9. Organizations should have clear guidance for the care of patients who are transgender and gender-diverse. This should include specific educational materials to increase awareness of issues impacting their access to high-quality care.
10. All areas of peri-operative and perinatal practice should embrace gender-inclusive language to honor all identities.
11. Pregnant patients who are transgender or gender diverse should be seen in an anesthetic clinic in the antenatal period to inform and support decision-making and plan care before presenting in labor.

The authors conclude, "The objective of this document is to guide best practice to ensure the safety and dignity of transgender and gender-diverse people in the peri-operative period. While they may have specific health needs in relation to gender dysphoria, their health requirements go beyond their gender identity. Most doctors will provide care to someone who is transgender or gender-diverse at some stage in their career. It is therefore important that all anesthetists are educated on specific considerations when caring for these patients.

"This document provides the first guidance produced to advise on best practice to ensure the safety and dignity of trans and gender-diverse individuals in the peri-operative period."