In this study, we present the first descriptive anesthesia case series of transgender youth undergoing gender affirmation surgery. From our study, we describe establishment of an anesthesia care service designed to meet the specific needs of gender-diverse youth undergoing gender reassignment surgery.
4.1. Development of GASPP
Our perioperative services have seen an increasing number of transgender patients scheduled for procedures (gender affirming and routine). These patients present with significant complexities in the perioperative period (
Table 4). In response to the clinical needs presented by this population, in November 2019, a core team of pediatric anesthesiologists, certified registered nurse anesthetists (CRNAs), an administrative lead, and a research nurse formally established the Gender Affirming Surgical Perioperative Program (GASPP). The primary objective of the GASPP was to appropriately address the preoperative (e.g., anxiety and comorbidities), intraoperative (e.g., unique anesthesia considerations), and postoperative needs (e.g., pain management and outcomes) of this unique patient population. The additional objectives of the GASPP were to provide welcoming and culturally sensitive care for gender-diverse patients and their families, with a consistent team of providers.
In addition to emotional and behavioral issues, transgender patients frequently have co-existing morbidities such as obesity, substance abuse, and congenital disorders, which could affect surgical planning and outcomes [
9]. Prior to the development of GASPP, patients first met with their anesthesia and perioperative team on the day of surgery for a routinely scheduled procedure. The GASPP team recognized that these patients required more extensive preoperative evaluation and preparation, acknowledged the need for a dedicated anesthesia team for surgical planning, and initiated a partnership with the Center for Gender Surgery (CfGS) to participate in care coordination. (
Figure 1) [
4]. The creation of the GASPP team also fulfilled the purpose of supporting the institution’s mission of comprehensive and affirming health equity for all [
4].
Beginning in June 2019, a GASPP attending anesthesiologist and CRNA were pre-assigned to each gender-affirming procedure to facilitate a multidisciplinary approach to patient care, and in-depth planning and communication. The goal was to provide consistent care through multi-staged procedures. The care coordination and anesthesia team-based approach was formulated after the Pediatric Perioperative Surgical Home model [
15]. Furthermore, an official GASPP email was created to offer clinicians, patients, and their families direct communication. This communication channel allows for individualized care planning between primary care, surgery, anesthesia, nursing, the patient, and family.
4.2. Initiatives of GASPP
The GASPP team instituted several initiatives to improve the transgender perioperative experience (
Table 5). Anesthesia management guidelines were created for each surgical procedure with the intent to improve clinical outcomes, decrease adverse events, and improve patient and team satisfaction. Anesthesia guidelines for chest reconstruction, phalloplasty, and vaginoplasty procedures were developed by applying evidenced-based anesthesia principles and experiential knowledge gained from gender affirmation cases. Capturing all the elective gender-affirming procedures from 2019–2020, GASPP members continuously reviewed the data to tailor and update anesthesia management to improve perioperative outcomes and adapt to changing surgical techniques. The clinical pearls are posted on the departmental internal website and are used as a management guideline by all anesthesia providers.
The benefits of working with a gender-focused, dedicated anesthesia team extend far beyond the experiences of each individual patient. Multidisciplinary collaboration, continuity of care, and application of evidence-based care principles of pediatric anesthesia practice are fundamental to the success of the GASPP. McIntosh [
16] advocates that healthcare providers in interdisciplinary teams who communicate effectively in the complex care of transgender patients help to reduce gender dysphoria and produce improved outcomes and patient care experiences [
16].
Through a careful process of outcome evaluation, collaboration with surgeons, and consultation with perioperative nursing teams, we enhanced and codified our individualized anesthesia considerations for chest and genital surgeries. There is a growing literature comparing Enhanced Recovery After Anesthesia (ERAS) pathways in adult surgical procedures, and a few reports of ERAS protocols are emerging to streamline pediatric perioperative care and improve patient outcomes. In a review and meta-analysis of Enhanced Recovery After Anesthesia (ERAS) pathways of adult breast reconstruction patients, the evidence supported the reduction in postoperative opioid use and a decrease in length of hospital stay with a mean difference of 1.7 days compared to traditional care [
17]. In a retrospective study of 57 female-to-male transgender adult patients undergoing chest contouring surgery, 84.2% were discharged to home within 24 h after their procedure [
18]. In our chest reconstruction anesthesia guideline, we recommend a combination of antiemetic medications (scopolamine patch, corticosteroid, and 5-HT3 antagonist) and intraoperative intravenous infusions of propofol to minimize PONV. Persing et al. [
19] recommend multimodal PONV prophylaxis and total intravenous anesthesia (TIVA) techniques in adult ERAS pathways for breast reconstruction to mitigate risk of nausea and vomiting [
19]. Our findings after chest reconstruction surgery are aligned with the findings in the adult literature. Creation of this service and implementation of population-specific anesthesia protocols may decrease opioid requirements and postoperative nausea and vomiting.
Adolescents who identify as transgender and gender nonconforming experience a high rate of stigma in the hospital environment and face inequitable access to primary care and mental health resources compared to their cisgender peers [
20]. Severe anxiety, trauma responses, suicidal ideation, and self-harm, in addition to experience-based fears of healthcare discrimination, are only a few of the challenges faced by patients [
2,
21,
22]. This complicated psychological constellation can be quite challenging for health providers unfamiliar with this population. Unintended misidentification such as misgendering can contribute to patient anxiety and dissatisfaction, as well as creating provider discomfort [
2]. The creation of our GASPP allowed us to maximize the awareness of these issues among the providers caring for these patients and may well have added to the positive outcomes we report.
Gender-affirming surgery has been shown to improve quality of life. Although current research has been focused mostly on adults, a study of 136 youth demonstrated significant improvements in chest dysphoria in transmasculine individuals undergoing chest reconstruction [
8]. A prospective study of 190 transfeminine adults undergoing gender affirmation surgery found that their short-term data support an improved quality of life after gender affirming surgery, although long-term data was still needed [
23]. A systematic review of seven studies involving 420 persons (259 transfeminine and 122 transmasculine individuals) on quality of life (QOL) data in adults reported transgender individuals generally had improvements in body image and other areas associated with quality of life after gender-affirming surgery [
24]. Implementation of Patient-Reported Outcome Measures is reported in the literature to assess subjective outcomes for top and bottom surgery. However, more studies are needed to validate patient satisfaction surveys and instruments on quality of life after gender affirmation surgery in adults [
25,
26,
27]. Researchers are currently working on developing a comprehensive patient reported outcome measure for evaluating gender-affirming treatments—the GENDER-Q [
28].
Care coordination between anesthesia and surgical staff has allowed GASPP team members to anticipate and plan for surgeries well in advance. As more gender-diverse youth require general anesthesia for dental, orthopedic, and other non-gender-affirming procedures, the GASPP team can offer continuity of care that fosters a milieu of trust and familiarity with their transition journey. The study by Kattari et al. [
29] on transgender-inclusive providers and mental health outcomes show gender-diverse patients having a transgender-inclusive provider were less likely to report symptoms of depression, anxiety, and suicide, compared to those who did not report having a transgender-inclusive provider.
There were several limitations in our study. It was a retrospective case series based on multiple anesthesia records and patient medical charts subject to variability on individual documentation practice and limitations of what data is routinely recorded. All records were manually audited to confirm the correctness of the perioperative, PACU, inpatient data, including gender identity, diagnosis, type of surgery, medications, and adverse events within the Anesthesia Information Management System (AIMS) record and medical records. The gender-affirming procedures were performed in a single center at our main hospital and satellite surgery center. Surgical techniques for genital procedures varied depending on the surgeons’ desired method and evolved over the course of this study.
Future studies are needed to compare various anesthesia techniques for optimizing outcomes after different procedures for this population. Creation of this service and implementing population-specific anesthesia protocols may decrease opioid requirements and postoperative nausea and vomiting. The GASPP team is in the process of adapting anesthesia guidelines into formal Enhanced Recovery After Anesthesia (ERAS) protocols and working to develop prospective studies to follow perioperative anxiety, patient satisfaction, and quality of life for transgender children and adolescents.