Current challenges faced by transgender and gender-diverse patients and providers in anesthesiology.

Abstract

The transgender and gender-diverse (TGD) population of the United States is estimated to be approximately 0.5% of the adult population or about 1.3 million adults.1 Of those adults, 38.5% are transgender women, 35.9% are transgender men, and 25.6% are gender-diverse.1 Mirroring the overall increase in the lesbian, gay, bisexual, transgender, and queer (LGBTQ+) population of younger Americans, the population of TGD adolescents is also increasing, now estimated to be at around 1.4% (∼300,000) of adolescents aged 13 to 17 years.1 Although social representation and acceptance of TGD individuals have slowly increased over the past decade, significant discrimination and mistreatment persist and are prevalent even within the health care system.2 In a 2016 survey, 33% of gender-diverse adult respondents experienced discrimination when interacting with health care providers and 23% avoided seeking medical care because of the fear of further mistreatment.3 A 2022 study similarly revealed ∼33% of gender-diverse individuals who experienced health care discrimination and found one-third of respondents reported health care avoidance, an increase since the 2016 study.4 Anesthesiologists play an important role in providing gender-affirming perioperative care and can actively mitigate further health care discrimination against TGD patients of all ages.5–7 As patient advocates and anesthesiologists strive to provide informed and culturally competent care for all patients, educational materials and opportunities to learn about gender-affirming perioperative care are severely lacking.8 In a 2021 survey of nearly 400 pediatric anesthesiologists, 92% of respondents agreed or strongly agreed that learning about transgender health care was relevant to their practice, yet 65% believed the amount of formal education they received was inadequate.8 Only half of the respondents felt equipped with the knowledge necessary to provide perioperative care to TGD patients.8 In an evaluation of the sexual and gender minority (SGM) educational content within obstetric anesthesiology fellowship programs in the United States and Canada, only 19% of program directors reported that SGM education was included in their curriculum and only 31% wanted to include SGM educational content for their trainees.9 Blanchard and colleagues identified several behavioral factors that predict anesthesiologists’ intent to provide culturally competent care for TGD patients. They determined that a positive attitude toward gender-affirming care (GAC) was the strongest predictor of intent, whereas a general lack of understanding of the transgender community and scarcity of educational opportunities led to provider uncertainty and decreased intent.10 These publications highlight an obvious need for more education specifically directed to anesthesiology providers regarding gender-affirming perioperative care. Accordingly, this article seeks to expand anesthesiologists’ understanding of gender-affirming perioperative care within the relevant social and ethical contexts by (1) examining the current political and legislative challenges faced by TGD individuals, (2) discussing the complex role of conscientious objection in providing GAC, and (3) briefly exploring the experiences of TGD colleagues during medical education and within the field of anesthesiology. To improve the overall knowledge of perioperative considerations, this article will also include an overview of the major considerations for gender-affirming perioperative care for TGD adults and adolescents. Legislative challenges affecting access to gender-affirming care At the federal level, the LGBTQ+ community is currently protected from health care discrimination under the Health Care Rights Law (Section 1557 of the Affordable Care Act, ACA),11 which prohibits discrimination based on sex, but the road to achieve this was hindered by political and legislative battles. The Supreme Court of the United States determined that sexual orientation and gender identity would fit within the Title VII definition of “sex” in Bostock v. Clayton County, GA on June 15, 2020.12 Within a few days of the ruling, the Trump administration Department of Health and Human Services revoked the nondiscrimination protections, which included sexual orientation and gender identity, thus allowing legal health care discrimination against the LGBTQ+ community.13 In May 2021, an executive order from the Biden administration restored the inclusion of gender identity and sexual orientation within the health care discrimination protections outlined in the ACA.14 Although executive orders are useful protective steps, wide-reaching federal legislation would better protect the LGBTQ+ community.15 The Federal Equality Act, first introduced in 2015, would do exactly that but has failed to pass Congress 4 times. As of July 2022, the Equality Act (HR 5) has been idle in a Senate committee after being passed by the House in February 2021.16 In the absence of federal nondiscrimination protections, state legislatures have introduced a multitude of bills that aim to redefine and limit the rights of TGD Americans. Before 2020, no state had considered antitrans legislation; yet from January 2021 to the present, 39 antitrans bills have been passed, while 20 more are being considered across the country.17 As of March 2022, 238 anti-LGBTQ+ bills had been filed—with nearly half targeting TGD Americans.17 Although access to GAC is the primary focus of this discussion, it should be noted that numerous states are attempting to restrict public school educational curricula that include gender identity, deny TGD individuals’ access to public restrooms, and ban transgender youth from participating in sports. Ohio’s Save Women’s Sports Act (passed in the Ohio House of Representatives and now awaiting Senate vote) requires an internal and external reproductive anatomy exam, testosterone measurements, and a chromosomal analysis of any athlete thought to be a transgender.18 The juridical vulnerability experienced when TGD individuals are subjected to the legal authority of lawmakers cannot be underestimated. Societal and legislative discrimination likely weigh heavily on TGD Americans, negatively affecting mental health, much like the experiences of lesbian, gay, and bisexual Americans during the legal battles for marriage equality.19 In fact, 94% of LGBTQ+ youth in 2021 reported politics negatively impacted their mental health.20 TGD adolescents are already at increased risk for mental health issues, substance use, and suicide, with roughly 35% of transgender adolescents attempting suicide.21,22 This already-vulnerable population is currently contending with a large-scale legislative movement seeking to restrict their access to GAC—including puberty suppression, affirming hormone therapy, and certain surgical procedures—which has long been accepted by nearly all American major medical associations as medically necessary treatment for TGD individuals experiencing gender dysphoria.23–25 Despite this, most state bills opposing GAC for adolescents are based largely on medical misinformation, which promotes inaccurate beliefs and perpetuates societal stigma against the TGD community. The Williams Institute estimates that ∼58,000 transgender youth (ages 13 to 17) are at risk of losing access to GAC and being forcefully detransitioned due to the current proposed state bans and policies.1 Currently, 15 states are considering or have already passed laws impacting adolescent access to GAC (Table 1).1,17 The Arkansas “Save Adolescents From Experimentation (SAFE) Act” was passed in April 2021, overriding the governor’s veto, becoming the first state law in the nation prohibiting and criminalizing gender-affirming health care for adolescents.26 This law also requires teachers and school counselors to inform parents if their child reveals that they are transgender, forcefully outing them and placing them at potential risk of physical harm, homelessness, or even increased suicidality. This law was subsequently blocked by a district court in July 2021. Another strategy employed by politicians to ban GAC has been the use of state regulations and executive orders by governors to sidestep the legislative process and enact restrictions without formal law. The governor and district attorney of Texas unilaterally declared GAC as “child abuse,” thus subjecting parents of TGD adolescents to investigation and family separation. This order has since been blocked.27 Considering the current legal landscape, parents and patients alike are expressing fear that these discriminatory bills will lead to worsening mental health and increased suicidal ideation.28 Although most proposed legislation discussed so far aims to criminalize GAC for adolescents, there is growing concern that legislators intend to eventually ban GAC for all ages, not just minors. For instance, bills in Alabama, North Carolina, Oklahoma, Texas, and Missouri seek to ban GAC for individuals in their early twenties.1,17 Perhaps, the most extensive method of banning GAC for all ages can be seen in at least 12 states that prohibit access to GAC through Medicaid, which directly affects ∼32,000 TGD Medicaid beneficiaries living in these states.29 These are only a few examples predicting a more restrictive and harmful trajectory of antitrans legislation. Table 1 - State legislative bills (proposed and/or passed) seeking to restrict gender-affirming care. AZ (8) MO (7) OH (6) KY (6) TN (6) OK (5) LA (5) NC (4) AR (4) TX (3) GA (3) KS (3) AL (2) ID (2) SC (2) IA (2) Allows or requires state medical licensing boards to discipline HCPs ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ Allows private citizens to file civil lawsuits against HCPs for providing any GAC to minors ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ Classifies the act of providing GAC to minors as a felony (*TN: misdemeanor) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ Penalizes parents who help minors access GAC ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ Prohibits specific insurance companies from covering GAC ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ Prohibits the use of state funds and denies additional funding to any organizations that provide GAC ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ Prohibits the use of government facilities and prohibits government employees from providing GAC ✓ ✓ ✓ ✓ ✓ ✓ Excludes GAC as tax deductible expense ✓ ✓ ✓ ✓ Classifies GAC as ‘Child Abuse’ ✓ ✓ ✓ Source: Williams Institute 1 and Trans Formation Project Legislation Tracker.17AL indicates Alabama; AR, Arkansas; AZ, Arizona; GA, Georgia; GAC, Gender-Affirming Care; HCP, Health care Providers; IA, Iowa; ID, Idaho; KS, Kansas; KY, Kentucky; LA, Louisiana; MO, Missouri; NC, North Carolina; OH, Ohio; OK, Oklahoma; SC, South Carolina; TN, Tennessee; TX, Texas. Some alarming themes found within the current antiGAC bills are the consequences laid out for parents and the criminalization of providers who support TGD adolescents’ access to GAC. In 8 states, the proposed bills penalize parents for supporting children through their gender journey and 3 states are attempting to classify GAC as child abuse (Table 1).1,17 Similarly, anesthesiologists and other providers in these states may face fines, medical license suspensions, and criminal prosecution for providing perioperative GAC to TGD individuals undergoing gender-affirming procedures. Many bills classify the act of providing GAC as a felony, subject to a prison sentence of 1 to 10 years.1,17 Numerous states also allow or require state medical boards to discipline their licensees if accused of providing GAC for adolescents.1,17 Moreover, 10 states are also considering bills that allow private citizens to file civil lawsuits against those providing GAC for adolescents.1,17 The disturbing trend—allowing criminal and civil litigation against medical professionals providing standard of care—emulates the same legal strategy directed against abortion providers. When the government interferes with the physician-patient relationship, anesthesiologists are faced with the dilemma of providing treatment for TGD adolescents at the personal and professional risk of being fined, imprisoned, or even sued in civil court. What remains to be seen is if state medical boards will respond to new bills by protecting providers or allowing punitive action. The myriad of antitrans bills in state legislatures across the country leaves the current legal landscape full of uncertainty with no guaranteed federal protections for TGD individuals. The legislative challenges affecting access to GAC are dynamic and will likely be different by the time this article is published; however, given the possible legal repercussions of providing GAC in antagonistic states, anesthesiologists are encouraged to familiarize themselves with their specific state laws. The progress of antitrans state bills can be followed through the Trans Formations Project website.17 Conscientious objection and discrimination when providing care for TGD patients Anesthesiologists would be naive to imagine practicing in a setting where they will not encounter TGD patients and be responsible for providing safe, high-quality anesthetic care. But what happens if an anesthesiologist desires not to be involved? Is there a role for conscientious objection, and is it permissible to “opt-out” or refuse to care for a specific patient population? Does it matter if the procedure is a gender-affirming surgery, an elective orthopedic procedure, or an emergent appendectomy? What if the person objecting is a trainee? Conscientious objection in health care refers to a health care professional’s “refusal to provide certain types of legal health care services to a patient based upon the provider’s personal moral, ethical, or religious beliefs.”30 While commonly applied to abortion, it has also been invoked regarding elective sterilization, emergency contraception, physician-assisted death, and in caring for LGBTQ+ patients.31 Similarly, in anesthesiology, it may be used to refrain from the care of patients seeking abortion or who refuse blood transfusion. Not surprisingly, the issue of conscientious objection in health care is controversial. An absolutist stance argues that the right to refuse should be protected on whatever grounds a provider uses to justify their refusal, supporting the notion that health care professionals have a right to define their scope of practice.32 However, without some restriction or oversight, there is risk of religious, ethical, or moral disagreement being used as “pretext for discrimination.”30 The incompatibility thesis, on the other hand, views conscientious objection as being contradictory to the obligations of the profession whereby doctors should provide services that are legal, efficient, and beneficial even if it conflicts with their personal values.33 Anesthesiologists have an obligation to provide medically appropriate and legal care when necessary; otherwise, there is risk that perioperative care will be inequitable or discriminatory. However, even Savulescu states, “When a doctor’s values can be accommodated without compromising the quality and efficiency of public medicine, they should, of course, be accommodated.”33 A third approach based on compromise is supported by many medical organizations, including the American Medical Association (AMA)34 and the British Medical Association (BMA),35 wherein a doctor’s right to conscientiously object is recognized but with limitations. To invoke conscientious objection, it is expected that (1) the reason for refusal is not discriminatory in nature, (2) principles of informed consent are upheld (including informing the patient of all relevant options, even if it includes ones that the provider morally objects to), (3) the care needed is not emergent, and (4) the doctor will refer the patient to other providers as to not delay appropriate care. The American Society of Anesthesiologists (ASA) has adopted the AMA Principles of Ethics36 and has additional guidance on conscientious objection in its ethics handbook.37 The lines between a provider’s personal, religious, or moral objections and outright discrimination may not always be clear. Refusal to provide care for a transgender patient solely because of their gender identity would be considered an objection against working with an entire group of people and, therefore, not justifiable. In contrast, an anesthesiologist’s objection to providing anesthesia for a specific gender-affirming surgery may not necessarily be discriminatory if they would morally object to the same procedure being performed for other types of people,31 but there is risk that it might be used to mask discriminatory intentions. All anesthesiologists should be expected to approach every patient with dignity, which at minimum includes respecting a patient’s pronouns and chosen name while refraining from misgendering, deadnaming, or using other stigmatizing language. Health care providers in the United States who choose to conscientiously object are protected by the federal law.30,38 Most states also have conscience protections, but these vary in scope and extent.30 Invoking conscience to refuse a medical service should not be viewed only as an issue of individual rights because it will always affect someone else, and health care providers exercising this right should be ready to handle potential consequences.39 Colleagues and associates may take offense to their beliefs or with the extra burden placed upon them to ensure the care of the patient is not interrupted. Any failure to fulfill professional obligations, compromise in care, or discriminatory action against the patient could result in professional disciplinary action or legal liability. For anesthesiologists contemplating invoking conscientious objection, careful consideration should be made to ensure their objection is not based on discrimination and that any potential legal or professional consequences have been considered. A unique concern for training program leadership teams is how to handle a trainee that reports a conscientious objection to working with TGD patients. Teelin et al40 lay out strategies for educators to employ in this specific situation, including 1) engaging the trainee in an honest discussion about their concerns to evaluate the legitimacy of their objection, 2) avoiding propagating stigma by modeling appropriate behavior in clinical settings approaching all patients with dignity, and 3) directing learners to evidence-based resources to ensure they acquire the necessary knowledge to professionally interact with the population in question. Care must be taken that trainees do not prioritize their own conscientious objection over their obligation to treat all patients with respect. Gender minority representation and experience within anesthesiology Until recently, gender minority demographic data was rarely, if ever, included in studies examining diversity within anesthesiology. Asking survey respondents to self-disclose gender identity is difficult since doing so relies on the respondent feeling safe enough to disclose; therefore, most estimates are likely underreported. The American Board of Anesthesiology (ABA) conducted a diversity survey in 2021, which revealed that 1% and 1.3% of diplomats were transgender or gender-diverse, respectively.41 The Accreditation Council for Graduate Medical Education (ACGME) does collect gender identity data (eg, male, female, and nonbinary), but does not ask about sex assigned at birth to help better determine the number of TGD anesthesiology trainees. In 2021, only 1 trainee reported being nonbinary, representing 0.01% of all anesthesiology trainees.42 The Society of Pediatric Anesthesia (SPA) also recently conducted a survey of its membership and found that 0.27% of respondents were transgender and no one selected identities outside of the male/female binary (unpublished data). Both the ACGME and SPA survey data suggest a lack of equitable TGD representation within anesthesiology that fails to reflect the populations served. Although comprehensive gender diversity data for anesthesiology trainees is lacking, similar data about medical students is available from the American Academy of Medical Colleges (AAMC). An encouraging trend is seen as the number of TGD individuals entering the medical school has been consistently increasing. The graduating medical students in 2021 were 0.7% gender-diverse43 and the incoming medical students reported 1.2% gender diversity.44 Unfortunately, TGD patients are not the only victims of discrimination and harassment within the health care system. SGM medical students also face higher incidences of bullying, harassment, burnout, depression, and suicidal ideation during their medical training when compared with nonSGM trainees, often leading to increased self-censorship (remaining in the closet) and concerns regarding specialty choice and career trajectory.45 Madrigal et al45 found that 39.8% of SGM medical students were advised to remain closeted and not be their authentic selves at work or in residency applications, whereas 67% also reported feeling anxious that their sexuality or gender identity would negatively affect their career trajectory. Regrettably, the field of anesthesiology had a low perceived acceptance of SGM identities, only scoring higher than the surgical specialties and neurology.45 It is unclear to what extent these trends in harassment and discrimination continue for TGD anesthesiologists after completing medical training because no TGD-specific data exists. Even in the absence of more comprehensive data, it is highly likely that TGD anesthesiologists experience increased harassment and discrimination within the anesthesiology workforce. Understanding the overall acceptance of and attitudes toward TGD anesthesiologists from colleagues remains difficult, but a 2021 ABA DEI survey revealed 73 disparaging comments made by diplomats regarding gender identity.41 Another recent study revealed that SGM individuals whose behaviors fit in with societal expectations for their gender role could better succeed within anesthesiology, whereas individuals who ‘stand out’ experience higher rates of workplace discrimination.46 This additional minority stress contributes to the higher rate of burnout and workplace discrimination experienced by LGBTQ+ attending anesthesiologists in the United States and discourages SGM anesthesiologists from being their true, authentic selves at work.47 This is unfortunate as increasing the visibility of TGD anesthesiologists is an important obstacle to overcome, not only to help improve the acceptance of gender minority identities within the specialty but also to make more TGD providers feel comfortable being their authentic selves at work, thus further increasing the much-needed visibility. Special care should be taken to protect TGD trainees and colleagues from discrimination within anesthesiology departments. Supporting SGM anesthesiologists should be of paramount importance to decrease the burnout and mental health disparities experienced by this population, and because role models and mentors were cited by 67.2% of medical student respondents as the most important factor when deciding to pursue anesthesiology training.48 If TGD anesthesiologists are not currently supported in the workforce, how can it be expected to recruit and retain enough TGD trainees to finally achieve adequate representation in our specialty? Considerations for gender-affirming perioperative care TGD individuals present with a similar range of surgical care needs as the majority cisgender population. A succinct, curated discussion for both adult and pediatric providers follows below to better educate anesthesiologists on the many nuances of providing gender-affirming perioperative care. Medical and surgical history In many cases, the initial medical treatment of gender dysphoria involves the use of gender-affirming hormone therapy (GAHT) (eg, testosterone, estrogen) and/or medications that block the effects of endogenous hormones (eg, spironolactone).24 As part of the preoperative assessment, it is critical to ascertain the patient’s treatment regimen and be aware of the associated side effects, pharmacologic interactions, and practice guidelines. Whether or not to discontinue hormone therapy is a common concern, mainly over concern for increased venous thrombo-embolism risk in transfeminine patients taking estrogen. The lack of evidence to support routine discontinuation of estrogen before undergoing planned surgeries leads to inconsistencies in general practice. Leading organizations such as the World Professional Association for Transgender Health (WPATH) recommend the continuation of estrogen therapy before and after surgical procedures in transgender women who lack specific additional risk factors, such as smoking, family history, or the use of synthetic estrogens.23,49 Nevertheless, if the decision is made to stop estrogen before surgery it should always be discussed with the patient and decided in collaboration with their prescriber. Evidence also suggests there is no need to routinely discontinue testosterone in transmasculine patients before surgery. Testosterone can be aromatized to estradiol, theoretically increasing clotting risk; however, a recent systematic review did not demonstrate any increased association between venous thrombo-embolism complications and perioperative testosterone use.50,51 Hormones in cisgender individuals have been implicated in the development of obstructive sleep apnea (OSA). Both testosterone deficiency and replacement therapy are associated with increased risk of OSA.52 In a case series, 2 transgender men started on testosterone had new-onset OSA requiring continuous positive airway pressure therapy.52 In addition, the perioperative morbidity and mortality associated with spironolactone (frequently used by transfeminine individuals) have been studied extensively in the cisgender population. A placebo-controlled randomized trial showed no heightened risk of kidney injury for those taking spironolactone before surgery.53 A history of prior gender-affirming surgery may also be discovered during the preoperative interview. Anesthesiologists should be familiar with the range of facial feminization and masculinization procedures and their potential impact on airway anatomy. Mandibular angle reduction and a decrease in chin width and height may be performed as part of feminizing the lower face. Chondrolaryngoplasty involves reducing or shaving the thyroid cartilage prominence to minimize the appearance of the “Adam’s apple.”54 Procedures such as these can result in changes that may alter the alignment of the laryngeal and pharyngeal axes (eg, crowded oropharynx, shorter thyromental distance, decreased mandibular space) that may increase the difficulty of tracheal intubation. Scar tissue may decrease tissue mobility making mask ventilation challenging or obscuring anatomic landmarks needed when performing an emergent surgical airway. Vocal surgery also warrants special attention. Transgender women who have undergone vocal feminization, usually by anterior glottoplasty and vocal cord web formation, may have smaller glottic openings and require smaller endotracheal tubes.55 It is important to note that cricothyroid approximation may effectively remove the entire cricothyroid membrane and space. Transgender men who have had masculinization of the thyroid cartilage, usually by augmentation using a graft of rib cartilage, may have altered thyromental distance. Similar to the above, these procedures may lead to changes that make mask ventilation, intubation, and surgical airways more difficult.55 Risk stratification Risk models designed to estimate patients’ perioperative risk often include binary sex in the scoring systems (as opposed to gender-diverse variations), but do not account for the use of GAHT. The male sex is usually scored higher when these tools are used, and there is a significant chance of underestimating risk in transgender women if the tool for the female sex is improperly utilized. Examples of commonly used perioperative risk calculators that incorporate sex but fail to address GAHT include the: American College of Surgeons National Surgery Quality Improvement Program (NSQIP) Surgical Risk calculator, STOP-BANG score for obstructive sleep apnea, and the CHADS2-Vasc score for atrial fibrillation stroke risk. Given the lack of prospective data available, it may be advisable to select the binary sex that confers the highest risk for the particular risk being assessed so as to not underestimate it, but results must be interpreted with caution. Lab testing It is important to assess the appropriateness of a preoperative pregnancy test. The ASA Practice Advisory for Perinaesthesia Evaluation recommends that pregnancy testing may be offered to female sex patients of childbearing age for whom the result would alter the patient’s medical management, but it also states that the testing should not be mandatory and that each patient has the right to refuse screening. The 2021 update does not comment on transmasculine patients that were assigned female at birth56 and has subsequently caused confusion and even resulted in lawsuits. Fertility is unpredictably impacted by testosterone therapy, and transgender men with intact ovaries and uteri have conceived and carried pregnancies. Testosterone is not a form of contraception, and transgender men may have unintended pregnancies while amenorrheic.57 Moreover, there are many calculated laboratory parameters and reference ranges that routinely incorporate binary sex (eg, Cockcroft–Gault formula for creatinine clearance, modification of diet in renal disease glomerular filtration rate equation, hematocrit reference ranges). Refer