• Anesthesia Inclusive Practices Amidst Adversity: Caring for the Transgender Patient Part I

    By Jose Delfin Castillo III PhD, MSNA, CRNA, ARNP Former Member, AANA Diversity and Inclusion Committee

    In my 11 years as an anesthesia provider I have cared for and provided anesthesia to three transgender individuals. As a CRNA and member of the lesbian, gay, bisexual, transgender, queer, intersex, and asexual (LGBTQIA) community, I did not have formal and adequate education, training, or experience before interacting with transgender patients. I had many questions and encountered many challenges, such as terminologies and pronoun use, gender preference, the phase of transition, state of hormone replacement therapy (HRT), and stage of gender reassignment surgery. There is a considerable need among CRNAs and clinical practitioners to be proficient and competent in the care of transgender patients within the perioperative continuum. Part of one of the many initiatives of the AANA Diversity and Inclusion Committee, this article is the first of a two-part overview for practicing CRNAs on how to enhance patient care with transgender patients through cultural competency.

    Anesthesia Inclusive Practices Amidst Adversity

    Health disparities exist within underrepresented sectors of our population such as the LGBTQIA community.1 According to Newport,2 3.5 percent of American adults self-identified as LGBT in 2012. This number went up to 4.1 percent in 2016 and subsequently increased to 4.5 percent in 2017. In 2016, Flores, Herman, Gates, and Brown3 estimated that there were approximately 0.6 percent self identified transgender individuals. The transgender community includes 1.4 million Americans.4 Transgender members of our society encounter numerous issues and adversities, including use of public restrooms, harassment, discrimination, and bullying in academia and/or the workplace. They may also struggle with internal psychological, emotional, and social conflicts, specifically with society stigma of “male and female only” gender dictates. Decreasing transphobia, increasing support for transgender rights,5 and equating them with our fundamental human rights, are optimal goals in healthcare.

    Anesthesia Inclusive Practices

    Studies have shown that clinical practitioners may often hesitate and/or refuse to perform a task that is unfamiliar or unknown.6,7 Some CRNAs may at first be uncertain about or, unwilling, to professionally identify, interview, and provide anesthesia to transgender patients. CRNAs need exposure, education, and training on clear-cut policies, standards, guidelines, and anesthesia best practices for the transgender individual. A detailed discussion of inclusive anesthesia practices follows in parts one and two of this review.

    Preoperative Care

    Communication during the first encounter. In the professional setting, Miller8 identified communication as an area that needs improvement regarding the relationships between primary care physicians and transgender patients. Goldhammer and colleagues9(p59) mentioned that there is an “increasing visibility of transgender people and others who do not conform to traditional gender norms …” that can cause confusion when first meeting the patient. Per the University of California, Davis1 gender identity is no longer binary-restricted (i.e., girl/woman and boy/man), and according to Briggs10 can be nonbinary.
    Shires et al6 reported transgender patients having undesirable experiences in healthcare. Gender dysphoria commonly afflicts transgender patients. The World Professional Association for Transgender Health4(p2) defines gender dysphoria as “discomfort or distress that is caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth.” A transgender patient might be in the transition process, hence understanding the appropriate pronouns to use is necessary. Goldhammer and colleagues9 recommend avoiding gender identifiers like “miss” or “mister.” Tollinche et al11 strongly encourage practitioners to avoid using binary pronouns he or she, him or her, himself or herself, and ask the transgender patient about name and pronoun preferences. They, them, and themself are acceptable singular nonbinary pronouns.11 Practitioners should never guess the gender of the transgender patient.7
    These name and pronoun requests must be noted on all healthcare records, including electronic medical records (EMRs) with appropriate software identifying gender preference. A few EMR software programs offer extra drop-down boxes for gender (i.e., male to female [MtF] and female to male [FtM] designations) in addition to male and female.7,9 The transgender patient’s legal name and preferred name must be communicated to all healthcare providers caring for the patient throughout the perioperative continuum.
    Using the appropriate language and messaging tools can directly lead to positive encounters with transgender patients, which may contribute to their physical, psychological and social well-being.9 The transgender patient may have lawfully changed their name on all their legal documents (i.e., driver’s license, health insurance card, Social Security card, etc.), which may alleviate confusion and promote ease among healthcare providers.7

    Phases of transition. A transgender individual may transition from male to female (MtF) or female to male (FtM).4 Transitions can occur in phases that manifest physical, emotional, psychological, and social changes in the individual. According to Equality Florida’s executive director12 50 percent of transgender patients have battled with depression; 40 percent have attempted suicide during the transition; 20 percent have been refused care; 27 percent are uninsured; and 30 percent have postponed medical care for fear of being marginalized.
    Understanding the phases of transition with transgender patients can alleviate some of the confusion that may occur in the perioperative arena. The primary level of the transition process with either MtF or FtM could be as simple as changing their manner of dress to match their gender identity. The secondary level of transition includes HRT, with the final stage being sex reassignment surgery/surgeries.4
    Transgender patients enter the perioperative arena not only for gender reassignment procedures, but also for the usual predicaments of the general population, such as appendicitis, laparoscopic cholecystectomy, etc. To help design an anesthetic plan specific to a transgender patient’s needs, CRNAs need to be aware of the patient’s phase of transition to identify which medications the patient may be taking that interact with anesthesia and should be withheld weeks prior to surgery (e.g., androgen therapy with FtM patients).
    According to Smith,7 all healthcare providers should examine their own biases and preconceptions before caring for a transgender patient. If these biases and prejudices would affect the healthcare provider in accomplishing their case assignments and/or patient safety, an institutional policy should be in place to provide alternative care.7

    Coming Soon…

    Part two of this column will delve further into the CRNA’s role in caring for transgender patients in the perioperative arena. Topics will include mental health assessment, contour shaping, medications and coexisting diseases, intraoperative considerations, and postoperative care. Learn more about AANA’s continued DEI efforts here.


    1. University of California – Davis (UCDavis). (2018, December 13). LGBTQIA Resource Center Glossary. Retrieved January 12, 2019, from
    2. Newport F. (2018, May 22). In U.S., Estimate of LGBT Population Rises to 4.5%. Retrieved January 12, 2019, from
    3. Flores AR, Herman JL, Gates GJ, Brown, TNT. (2016, June). How Many Adults Identify as Transgender in the United States. Retrieved January 12, 2019, from how-many-adults-identify-as-transgender-in-the-united-states/.
    4. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People (SOC). (2017). Retrieved November 11, 2017, from The World Professional Association or Transgender Health website: publications/soc.
    5. Flores AR., Haider-Markel DP, Lewis DC, Miller PR, Tadlock BL, Taylor JK. (2018, May). Greater Visibility Reduces Transphobia and Increases Support for Transgender Rights. Retrieved January 12, 2019, from visibility-transphobia-lgbt-rights/ .
    6. Shires DA, Stroumsa D, Jaffee KD, Woodford MR. Primary care clinicians’ willingness to care for transgender patients. The Annals of Family Medicine, 16(6), 555-558. doi:10.1370/afm.2298
    7. Smith FD. (2016). Perioperative Care of the Transgender. Patient. AORN Journal, 103(2), 151-163. doi:10.1016/j. aorn.2015.12.003.
    8. Miller J (2018, November 27). PCP-transgender patient relationships need improvement. Retrieved November 27, 2018, from https://www.healio. com/family-medicine/practice-management/news/ online/{fb4cff6c-94e3-4b57-b8e6-a32f904c0b1d}/. pcp-transgender-patient-relationships-need-improvement
    9. Goldhammer H, Malina S, Keuroghlian AS. Communicating with patients who have nonbinary gender identities. The Annals of Family Medicine. 2003; 16(6), 559-562. doi:10.1370/afm.2321
    10. Briggs E. (Planner). (2017, November 11). Transgender Health Care for Advanced Practice Nurses. Conference in College of Nursing, University of South Florida, Tampa.
    11. Tollinche LE, Walters CB, Radix A, Long M, Galante L, Goldstein ZG, Yeoh C. The perioperative care of the transgender Patient. Anesthesia & Analgesia. 2018; 127(2), 359-366. doi:10.1213/ ane.0000000000003371.
    12. Duncan G. Personal communication, November 11, 2017.