Care of transgender people: back to basics

It is our duty to care for our patients to the best of our ability and free from prejudice. The growth of the national conversation around transgenderism has revealed significant health disparities in this population, either through difficulties accessing basic healthcare or judgement when they receive it [1]. Around 37 countries have laws that de facto make it illegal to be transgender, and it is not possible to legally change one’s gender in 47 UN member states [2]. While it is legal to change one’s gender in the UK, our government continues to fail to ban conversion therapy of transgender people; recorded LGBTQ+ hate crimes are at the highest level that they have ever been, with a 56% increase in transgender hate crimes seen over the past 12 months [3].

The specific healthcare needs of transgender people are covered in very few undergraduate medical curricula and are entirely absent from the RCoA and the FICM postgraduate training curricula [4], yet in our opinion learning about the safe care of transgender people should be a necessity. The Association of Anaesthetists has recently taken steps to improve this with an educational webinar. A survey that we performed highlighted a sizeable gap in knowledge of UK anaesthetists about the peri-operative care of transgender patients [5]. We are currently working closely with groups including the ICS and the Association of LGBTQ+ Doctors and Dentists to try and bridge this gap. Whilst the intricacies of changes to airway anatomy, ventilatory mechanics, and peri-operative hormone therapy can be complex and require the development of formal guidance, there are many simple actions we can take to improve the day-to-day experiences of these patients [6].

Firstly, some terminology. Table 1 explains some core definitions for concepts that are frequently misunderstood. Once this is clear, the next important step is to understand the use of patient pronouns. Commonly used pronouns include:

• Feminine – she/ her/ hers 
• Masculine – he/ him/ his 
• Non-binary – they/ them/ theirs

Some clinicians have reported feeling uncomfortable asking a patient’s preferred pronouns, but compared to the complex discussions we regularly have with our patients undergoing life changing surgery this enquiry should be relatively simple [5]. Some other indirect methods to facilitate this include having pronouns on name badges, and inputting pronouns in email sign-offs. When asking about pronouns it is important to acknowledge that patients may be at different points in their transition journey and may not be open about their gender identity with family or friends; thus, once a patient’s preferred pronouns and gender identity have been established, it is important to ascertain who they are happy for this information to be shared with and how they would like to be addressed in the presence of visitors.

It is common for people to question the value of indicating their preferred pronouns if they do not identify as transgender or non-binary. In our opinion this is about a change of culture, and the creation of a safe space where patients, and indeed colleagues, can feel comfortable to express their gender identity more freely if confirmation of pronouns is more accepted and widespread.

Another key non-medical aspect of trans care is use of the correctly gendered wards. Where possible patients should be admitted to the ward that aligns with their gender identity. There may be occasions where this can be logistically challenging, such as trans men undergoing hysterectomy who are routinely admitted to a gynaecology ward. In such cases this should be discussed with the patient, and every effort should be made to satisfy their wishes where possible. Use of side rooms is a common measure when this situation proves challenging.

It is also important to note that not all transgender persons are the same. Some wish for only social transition (this can include pronouns and physical identity of their affirmed gender), some wish for medical transition (including hormonal therapy), and some wish in addition for surgical therapy to affirm their gender.

There remains a long way to go until the healthcare inequalities suffered by transgender patients are rectified, but these small simple steps are an easy place to start.

Acknowledgements: we would like to thank the Association of Anaesthetists and the Association of LGBTQ+ Doctors and Dentists for their ongoing support of this work.

Luke Flower
Elected Member, Associated of Anaesthetists Trainee Committee
Honorary Clinical Research Fellow and Anaesthetic ACCS4 Trainee, London School of Anaesthesia

Kamilla Kamarrudin
General Practitioner in Transgender Healthcare, East of England Gender Service

Stuart Edwardson
Honorary Secretary, Association of Anaesthetists Trainee Committee
ST5 in Anaesthesia and Intensive Care Medicine, South-East Scotland School of Anaesthesia

Twitter: @LukeFlower1; @drkamillak; @scotgasdoc

References 

1. Stonewall | LGBT in Britain - Trans Report, 2018. https://www.stonewall.org.uk/lgbt-britain-trans-report (accessed 1/11/2022). 
2. Forbes. New report shows where it’s illegal to be transgender in 2020, 2020. https://www.forbes.com/sites/jamiewareham/2020/09/30/this-is-where-its-illegal-to-betransgender-in-2020/?sh=1eaf2ff5748f (accessed 1/11/2022). 
3. BBC News. Hate crimes recorded by police up by more than a quarter, 2022. https://www.bbc.co.uk/news/uk-63157965 (accessed 1/11/2022). 
4. Royal College of Anaesthetists. 2021 Anaesthetics curriculum, 2021. https://rcoa.ac.uk/training-careers/training-hub/2021-anaesthetics-curriculum (accessed 1/11/2022). 
5. Flower L, Edwardson S. Peri-operative management of transgender patients: time for some guidance? Anaesthesia 2022; 77: 1313-4. 
6. Flower L, Kamarrudin K, Lennie Y, Edwardson S. The perioperative management of transgender patients: a knowledge gap we can no longer ignore. British Journal of Hospital Medicine 2022; 83: 1-6.

Table 1.

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