Perioperative care of transgender and gender diverse adults

Question 1

Recommendations for communication with transgender patients

Answer 1

• Use preferred name and pronouns
• Allow discrete disclosure of sex and gender at birth in pre-op assessment
• Transgender status should only be shared with other clinical teams if relevant to patient care
• Should be cared for in an environment that respects their gender identity (may necessitate a side room)
• Gender-inclusive language should be used in hospitals

Question 2

Pre-operative considerations for transgender patients

Answer 2

• Need pregnancy test for any patient with uterus/ ovarian tissue between ages 12-55 yrs
  Airway assessment-
• cricothyroid approximation surgery means the patient has no cricothyroid membrane (no eFONA)
• recent vocal cord surgery no airway instrumentation for 8-12 weeks unless absolutely necessary

Question 3

Intra-operative considerations for transgender patients

Answer 3

• Chest binders should be removed prior to anaesthesia (restrictive ventilation)
• TCI models are not validated with hormone therapy therefore pEEG monitoring at all times
• Continue hormone treatment throughout peri-op period
• Topical hormonal therapies may increase uptake if warmed during surgery
• High oestrogen levels depress albumin = increased free bupivacaine levels

Question 4

Hormone therapy in the transgender population

Answer 4

1. Gonadotrophin- releasing hormone analogues
   - Prevent the onset of puberty
   - Suppress testosterone and oestrogen release
   - Reversible if stopped
   - Can reduce height velocity and peak bone mass
2. Testosterone (Masculinising)
   - Hb will reach male concentrations within 3/12
   - Thicker vocal cords and lower-pitched voice
   - Hair growth, menstrual suppression
   - Increased muscle mass, reduced fat- pharmacokinetic implications
   - Risks- polycythaemia, increased cholesterol, alopecia, acne, increased MI risk
3. Oestrogens and anti-androgens (Feminising)
   - Spironolactone, finasteride, GRH analogues
   - Increase fat mass, reduce muscle, and breast development
   - Skin softening, reduced testicular size
   - Increased risk osteopenia, VTE

Question 5

Common surgical procedures for transgender patients

Answer 5

• Airway and facial surgery- mandible augmentation/ reduction, chin augmentation
• Cricothyroid approximation – cricoid cartilage is pushed posterosuperiorly through cervical incision and thyroid anteroinferiorly. This can remove the cricothyroid membrane and make eFONA impossible
• Laryngoplastic- removal of anterior thyroid cartilage to reduce diameter of larynx
• Mastectomy
• Vaginoplasty
• Phalloplasty
• Gonnadectomy
• Hyterectomy

Question 6

Post-operative considerations for transgender patients

Answer 6

• Location of care should be in an environment that respects gender identity
• Taking testosterone- increased MI risk
• Taking Oestrogens- Increased, CVA, VTE, PONV risk
• Taking spironolactone- increased risk of AKI