Care of Transgender and Gender-Diverse Patients

Care of Transgender and Gender-Diverse Patients Practice and Policy Considerations

Background American Association of Nurse Anesthesiology (AANA)’s mission supports that nurse anesthetists have a responsibility to all patients to provide high quality and patient centered care that is individualized to meet their healthcare needs. AANA’s Position Statement on Diversity, Equity and Inclusion also states that nurse anesthetists provide care by advocating for civility and assisting in the elimination of health disparities in an effort to improve health outcomes for diverse patients and communities. AANA embraces members of the LGBTQIA+ community, including transgender or gender-diverse patients, and recognizes that nurse anesthetists play an integral role in promoting and advocating for quality healthcare for these patients.

The World Professional Association for Transgender Health (WPATH)’s Standards of Care provide recommendations for the training of health care professionals and assessment standards for transgender or gender-diverse patients.6 Some highlights of these recommendations include: • Institutions develop competencies and learning objectives for transgender and gender diverse health that can be incorporated into specialty competency areas6 • Orientations and continuing education should include cultural competency training regarding transgender and gender-diverse patients6 • When providing gender-affirming treatment, providers should consult with other health disciplines or specialties6 These recommendations provide valuable guidance for CRNAs and other healthcare professionals.

Purpose AANA believes that it is imperative for Certified Registered Nurse Anesthetists (CRNAs) to provide compassionate, holistic, patient centered anesthesia, pain management, and related care regardless of the patient’s race, ethnicity, culture, religion, sexual orientation, or gender identity.

This document aims to highlight the impact of health inequities for transgender patients and how it affects care outcomes. In addition, the document will discuss practice considerations and best practices for CRNAs and facilities to develop effective policies and strategies that promote equitable and inclusive care for transgender and gender-diverse patients.

Practice Considerations There are many perioperative practice considerations for CRNAs as they care for transgender and gender-diverse patients.

1 of 9 American Association of Nurse Anesthesiology 10275 West Higgins Road, Suite 500 | Rosemont, IL 60018 Professional Practice Division l 847-655-8870 l practice@aana.com

Preoperative Care Assessment and Evaluation CRNAs are involved in many aspects of a patient’s preoperative care including education, performing a comprehensive medical history and physical, and conducting a preanesthesia assessment and evaluation.7 CRNAs should understand terminology specific to LGBTQIA+ patients. For a transgender and gender-diverse patient, it is important for the CRNA, as well as other healthcare providers, to address the patient by their gender-affirming name and pronouns.8 Examples of common pronouns include, she/her/hers, he/him/his, they/them/theirs, however, there are additional pronouns that may be used as well (e.g. ze or zir).9 In addition, providers should avoid using a deadname, as indicated by the patient.10 Providers should use the correct gender-affirming pronouns and names in a patient’s EHR as much as possible (based on the allowance of the EHR).11 Many systems have the ability to capture sex, gender, gender-affirming pronouns, and anatomy.12 Clinicians should take special care to correctly input and review this data for patient wellness and care, and for legal and medical billing purposes.12, 13 The Center for Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC) instituted a regulation that all EHRs certified by the Meaningful Use incentive program be able to capture and record data regarding sexual orientation and gender identity (SOGI) by 2018.12 It should be noted that for gender nonbinary people, it may be difficult to capture nonbinary markers in a medical record or legal documents.14, 15 Health Considerations and Medications The anesthesia provider should be familiar with gender-affirming hormone therapy medications.8 There is no clinically significant documented drug interaction with common puberty suppressing or gender-affirming hormone therapy drugs and anesthesia medications.8, 13 Discussions about continuing gender-affirming hormone therapy (such as estrogen or testosterone) prior to surgery should include the patient and the provider prescribing the medication.16 As with any patient, other medications that should be reviewed by the anesthesia provider include anti-depressants, anti-anxiety, anti-psychotics and psychotropics, prophylactic and Human Immuno-Deficiency Virus (HIV) drugs.17 Studies have shown that prevalence of HIV, depression and anxiety is higher in transgender people when compared to the general population.6 Other risk factors to be considered include smoking and substance use as this could affect the airway or other anesthesia administration.18 As part of reviewing a patient’s medical history, it is important to note if surgery on the vocal cords or facial feminization or masculinization procedures have been done previously, as this could effect a patient’s airway.8, 13, 16, 19 Another health consideration for this population is contour shaping. The anesthesia provider should be familiar with contour shaping and the effect it could have on respiration or other systems (i.e., urinary system). If the patient is utilizing contour shaping items, a discussion must occur about the timing of removal and continuation of chest binding items.8 Chest binding could have an impact on lung volume and respiration.8, 20 The removal of chest binding items is also important for postoperative care to mitigate cardiopulmonary derangements.19

2 of 9 American Association of Nurse Anesthesiology 10275 West Higgins Road, Suite 500 | Rosemont, IL 60018 Professional Practice Division l 847-655-8870 l practice@aana.com

Anesthesia providers may need to conduct pregnancy tests to confirm that the procedure will not harm the fetus. In general, the patient who still possesses the anatomy for reproduction would need to have the following to be considered for a pregnancy test: uterus and ovaries, receptive vaginal/frontal sex; and sexual partners that can produce sperm.8 Due to psychological distress, patients should be informed of the possibility of pregnancy testing and given an option of the testing method.8, 13 Intraoperative & Postoperative Care Intraoperative care should be personalized based on the preoperative information provided to the nurse anesthetist.17 Based on the patient’s medical history, considerations may need to be made for: • patients utilizing hormone replacement therapy o It may increase risk for patients with hypertension, diabetes mellitus, and coagulopathy (i.e., VTE or a cardiovascular event).6, 19, 21 o If a patient is taking estrogen, there may need to be a discussion about continuing or discontinuing use.16 In comparison to the general population, hormone therapy for transgender women leads to a higher prevalence of venous thrombosis, myocardial infarction, CVD, and Type 2 diabetes.19 • increased risks for transgender women, as they have a higher incidence of HIV infection13 CRNAs assisting with voice feminization surgery that includes the use of a laser should also be aware of surgical fire risks and prevention methods.22 Similar to preoperative care, gender-affirming language should be used in the postoperative environment and with postoperative providers.17 Hospitals and institutions should establish facility policy in regards to placing transgender patients in private rooms, when possible, or with patients of the same gender identity if a shared room is necessary.23 Additionally, policies may include considerations for patients objecting to room sharing with transgender or gender-diverse patients.23 Any determination to relocate a patient to another room should be in a safe manner and be medically appropriate.23 If the patient has visitors, healthcare providers should discuss the patient’s preferences on information sharing while other people are present in the room.24

Policy Considerations CRNAs play an important role in the care of patients and recognizing and eliminating healthcare disparities. There are key strategies for CRNAs to address and identify disparities or discrimination at their institutions, which include: • Be consciously aware of one’s own implicit bias and exercise cultural humility: Transgender and gender-diverse patients may face stigmatization at the structural, interpersonal and individual levels when seeking out healthcare.5, 25 When CRNAs interact with patients with multiple marginalized experiences, understand and acknowledge that unless you share in the same multiple marginalized identities, you are unable to fully understand the patient’s experiences.25 3 of 9 American Association of Nurse Anesthesiology 10275 West Higgins Road, Suite 500 | Rosemont, IL 60018 Professional Practice Division l 847-655-8870 l practice@aana.com

• •

•

•

•

•

Be a patient advocate: CRNAs should advocate for their patients who experience discrimination or other injustices while receiving care.

Be aware of the community needs and professional development: CRNAs are encouraged to better understand the communities they serve, the needs of those communities, and whether resources are available to address those needs. CRNAs can take advantage of opportunities to interact with the transgender community through training sessions or courses to help create a respectful and trusting relationship.25 CRNAs can also participate in professional development opportunities, such as simulation scenarios, to help improve their confidence and knowledge when interacting with transgender and gender-diverse patients.26 Create an inclusive clinical setting: It is important that CRNAs help to develop, implement and maintain anti-discrimination policies and strategies at their facilities.27 Other ways to create an inclusive clinical setting is to display anti-discrimination policies for patients to see, or to utilize “safe space” language and visuals (e.g., a rainbow colored sign) in the facility or on the facility’s website.25 Improving the education of nurse anesthesia students: Nurse anesthesia education programs can take steps to integrate transgender-specific topics and content into curruculum.28 Nursing baccalaureate programs and graduate-level medical programs have gaps in educational content related to care for LGBTQIA+ patients.29, 30 Topics could include health inequities and gender-affirming language and interventions.28 Including these topics in curriculum can help nurse anesthesia students to better serve this population.28 Simulation would also be a useful tool for education of nurse anesthesia students.31 Other suggestions for integrating transgender and gender-diverse health education into curriculum includes having transgender and gender-diverse people on standardized patient panels, reviewing online modules or having an opportunity for transgender and gender-diverse health electives.4 Encourage transgender and gender-diverse students to consider the nurse anesthesiology profession. It is unknown the number of nurses or CRNAS that are transgender or gender-diverse, however, only .7% of medical students and physicians in the US self-identify as transgender or gender nonbinary.32 A 2021 American Board of Anesthesiology study reports that 1% of respondents were transgender and 1.3% were gender-diverse.16 The American Association of Colleges of Nursing (AACN) recognizes that diversity in nursing is important in eliminating disparities in the healthcare system, and it is important for nurses to be part of the populations of patients that they serve.33 It would follow that it would be similarly beneficial for transgender and gender-diverse patients to see themselves in the nurses and physicians that are part of their healthcare team.4 Be aware of current standards of care, state and federal laws and ethics. Multiple healthcare organizations provide information on standards of care and ethics when working with transgender and gender-diverse patients, especially for adolescent patients.6, 34-37 The AANA has a Code of Ethics for the Certified Registered Nurse 4 of 9 American Association of Nurse Anesthesiology 10275 West Higgins Road, Suite 500 | Rosemont, IL 60018 Professional Practice Division l 847-655-8870 l practice@aana.com

•

Anesthetist, which describes the CRNA’s responsibilities to the patient, the profession, and society.36 It is up to each healthcare provider or institution to keep up to date with current legislation (state or federal) that may affect healthcare treatment.

Focus on the best outcomes for the patient. With consideration for the specific and sensitive nature of care needed by LGBTQIA+ patients, it is important to recognize that the best outcome for the patient should be the ultimate goal in providing care. In situations where a provider has reservations about part or all of the procedure a patient is undergoing, a compromise approach is most reasonable.42 Conscientious objections should be allowed when based on concerns for the patient’s safety in cases where a procedure may be pathocentric or contrary to health preservation.43 Another remedy is transferring the patient to an appropriately credentialed anesthesia provider willing to perform the procedure, as recommended by the AANA Code of Ethics for the Certified Registered Nurse Anesthetist.

Conclusion Nurse anesthetists provide excellent patient care by advocating for awareness, promoting civility, and eliminating health disparities to enhance health outcomes for individuals, families, and communities. The AANA is dedicated to advocating for patient-centered care and improving health outcomes for members of the LGBTQIA+ community.

Glossary Agender: a person that does not identify as having a specific gender.8 Cisgender Male or Female: A gender identity or gender role that matches a person’s sex assigned at birth based on societal expectations.38 Chest-binding: The practice amongst transmasculine individuals to compress the chest tissue.

This could be done using household items or with a purchased compressive undergarment.8 Cultural Humility: “A process of openness, self-awareness, being egoless, and incorporating self-reflection and critique after willingly interacting with diverse individuals.”39 Deadnaming: Using the name that was assigned at birth if it differs from the name a patient has provided.10 Gender-Diverse: When a person’s sex assigned at birth does not correlate with their gender identity based on societal or cultural expectations. This also includes nonbinary, gender nonconforming, genderfluid, and agender people.8, 14 Genderfluid: A person’s whose gender expression or identity changes is fluid.8 Gender Identity: An individual’s idea of self as male, female, a combination of both or neither, including how someone addresses and views themselves.40 Gender nonconforming: “A person whose gender identity differs from that which was assigned at birth, but may be more complex, fluid, multifaceted, or otherwise less clearly defined than a transgender person.”14 Health inequity: The systematic disparity in health status for different groups of people.41 5 of 9 American Association of Nurse Anesthesiology 10275 West Higgins Road, Suite 500 | Rosemont, IL 60018 Professional Practice Division l 847-655-8870 l practice@aana.com

Interpersonal Stigma: “discriminatory actions carried out against a person due to the perpetrator’s conscious or subconscious negative views about a labeled group”.25 Individual Stigma: “the negative beliefs individuals have about themselves due to the internalization of structural and interpersonal stigma”.25 LGBTQIA+: This abbreviation encompasses lesbian, gay, bisexual, transgender, queer, intersex, and asexual people.38 Nonbinary: “transgender or gender nonconforming person who identifies as neither male nor female.”14 Structural Stigma: “the systematic devaluation of people through institutional policies and cultural norms that limit access to important social resources”.25 Transgender: When a person’s gender identity is different from their assigned sex at birth.14 Transgender Female: “someone with a female gender identity and a male birth assigned sex”.14 Transgender Male: “someone with a male gender identity and a female birth assigned sex”.14

References 1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

ANA Position Statement: Nursing Advocacy for LGBTQ+ Populations. OJIN: Online Journal of Issues in Nursing. November 19, 2018;24.

Jones JM. LGBT Identification in U.S. Ticks Up to 7.1%, 2022.

Safer JD, Coleman E, Feldman J, et al. Barriers to healthcare for transgender individuals. Curr Opin Endocrinol Diabetes Obes. Apr 2016;23(2):168-171.

Reddy A. Transgender Healthcare and Medical Education: An Inductive Thematic Analysis of Digital Discourse. Cureus. Feb 2023;15(2):e34972.

Velasco RAF, Slusser K, Coats H. Stigma and healthcare access among transgender and gender-diverse people: A qualitative meta-synthesis. J Adv Nurs. Oct 2022;78(10):3083-3100.

Coleman E, Radix AE, Bouman WP, et al. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. International Journal of Transgender Health. 2022/08/19 2022;23(sup1):S1-S259.

Scope of Nurse Anesthesia Practice: American Association of Nurse Anesthesiology 2020.

Roque RA, Reece-Nguyen T. Transgender and Gender-Diverse Patients: Anesthetic Considerations. Available at: https://www.openanesthesia.org/keywords/transgenderand-gender-diverse-patients-anesthetic-considerations/. Accessed March 20, 2023.

Pronouns and Inclusive Language. LGBTQIA Resource Center - UC Davis. Available at: https://lgbtqia.ucdavis.edu/educated/pronouns-inclusive-language. Accessed May 30, 2023.

HRC’s Brief Guide to Getting Transgender Coverage Right. Human Rights Campaign.

Available at: https://www.hrc.org/resources/reporting-about-transgender-people-readthis. Accessed May 30, 2023.

6 of 9 American Association of Nurse Anesthesiology 10275 West Higgins Road, Suite 500 | Rosemont, IL 60018 Professional Practice Division l 847-655-8870 l practice@aana.com

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

Alpert AB, Mehringer JE, Orta SJ, et al. Experiences of Transgender People Reviewing Their Electronic Health Records, a Qualitative Study. Journal of General Internal Medicine. 2022/05/31 2022.

Patel K, Lyon ME, Luu HS. Providing Inclusive Care for Transgender Patients: Capturing Sex and Gender in the Electronic Medical Record. The Journal of Applied Laboratory Medicine. 2020;6(1):210-218.

Tollinche LE, Walters CB, Radix A, et al. The Perioperative Care of the Transgender Patient. Anesth Analg. Aug 2018;127(2):359-366.

UCSF Gender Affirming Health Program DoFaCM, University of California San Francisco. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People. Available at: transcare.ucsf.edu/guidelines. Accessed March 14, 2023.

Kronk CA, Everhart AR, Ashley F, et al. Transgender data collection in the electronic health record: Current concepts and issues. J Am Med Inform Assoc. Jan 12 2022;29(2):271-284.

Reece-Nguyen TL, Tollinche L, Van Rooyen C, Roque RA. Current challenges faced by transgender and gender-diverse patients and providers in anesthesiology. International Anesthesiology Clinics. 2023;61(1):26-33.

Castillo III JD. Anesthesia Inclusive Practices Amidst Adversity: Caring for the Transgender Patient Part II: AANA Nurse Anesthesiology Lennie Y, Leareng K, Evered L. Perioperative considerations for transgender women undergoing routine surgery: a narrative review. British Journal of Anaesthesia.

2020/06/01/ 2020;124(6):702-711.

Tollinche LE, Van Rooyen C, Afonso A, Fischer GW, Yeoh CB. Considerations for Transgender Patients Perioperatively. Anesthesiol Clin. Jun 2020;38(2):311-326.

Van Rooyen C, Aquino NJ, Tollinche LE, Reece-Nguyen TL. Perioperative Considerations for Gender-Affirming Surgery. Current Anesthesiology Reports.

2023/06/01 2023;13(2):90-98.

Irwig MS. Cardiovascular health in transgender people. Rev Endocr Metab Disord. Sep 2018;19(3):243-251.

Roy S, Smith LP. Surgical fires in laser laryngeal surgery: are we safe enough?

Otolaryngol Head Neck Surg. Jan 2015;152(1):67-72.

Ask HRC: When Patients Object to Transgender Roommates. ECRI, 2018.

Aquino NJ, Ganor O, Chrisos HA, Oles N, Boskey ER. Perioperative Issues With Gender-Diverse Youth. Journal of Pediatric Surgical Nursing. 2021;10(1):23-31.

Garcia AD, Lopez X. How Cisgender Clinicians Can Help Prevent Harm During Encounters With Transgender Patients. AMA Journal of Ethics. 2022;24(8):E753-761.

Lund A, Russell K, Adkins D, Simmons VC. Simulation-Based Teaching to Improve Perioperative Care of Transgender Patients. Clinical Simulation in Nursing. 2022/05/01/ 2022;66:76-84.

Patient-Centered Care for Transgender People: Recommended Practices for Health Care Settings. Centers for Disease Control and Prevention. Available at: https://www.cdc.gov/hiv/clinicians/transforming-health/health-care-providers/affirmativecare.html.

7 of 9 American Association of Nurse Anesthesiology 10275 West Higgins Road, Suite 500 | Rosemont, IL 60018 Professional Practice Division l 847-655-8870 l practice@aana.com

28.

29.

30.

31.

32.

33.

34.

35.

36.

37.

38.

39.

40.

41.

42.

McDowell A, Bower KM. Transgender Health Care for Nurses: An Innovative Approach to Diversifying Nursing Curricula to Address Health Inequities. J Nurs Educ. Aug 1 2016;55(8):476-479.

Sherman ADF, McDowell A, Clark KD, Balthazar M, Klepper M, Bower K. Transgender and gender diverse health education for future nurses: Students' knowledge and attitudes. Nurse Educ Today. Feb 2021;97:104690.

Bleasdale J, Wilson K, Aidoo-Frimpong G, Gabriel SJ, Przybyla SM. Lesbian, Gay, Bisexual, and Transgender (LGBT) Health Education in Healthcare Professional Graduate Programs: A Comparison of Medical, Nursing, and Pharmacy Students. J Homosex. Aug 19 2022:1-14.

McCave EL, Aptaker D, Hartmann KD, Zucconi R. Promoting Affirmative Transgender Health Care Practice Within Hospitals: An IPE Standardized Patient Simulation for Graduate Health Care Learners. MedEdPORTAL. Dec 13 2019;15:10861.

Dimant OE, Cook TE, Greene RE, Radix AE. Experiences of Transgender and Gender Nonbinary Medical Students and Physicians. Transgender Health. 2019/12/01 2019;4(1):209-216.

AACN. Enhancing Diversity in the Workforce. Available at: https://www.aacnnursing.org/News-Information/Fact-Sheets/Enhancing-Diversity.

Accessed April 4, 2023.

Gender Dysphoria/Gender Incongruence Guideline Resources. Endocrine Society.

Available at: https://www.endocrine.org/clinical-practice-guidelines/gender-dysphoriagender-incongruence#1.

Adelson SL. Practice parameter on gay, lesbian, or bisexual sexual orientation, gender nonconformity, and gender discordance in children and adolescents. J Am Acad Child Adolesc Psychiatry. Sep 2012;51(9):957-974.

Code of Ethics for the Certified Registered Nurse Anesthetist. AANA. Available at: https://www.aana.com/docs/default-source/practice-aana-com-web-documents(all)/professional-practice-manual/code-of-ethics-for-the-crna.pdf?sfvrsn=d70049b1_6.

Informed Consent for Anesthesia Care Policy and Practice Considerations. AANA. Available at: https://www.aana.com/docs/default-source/practice-aana-com-webdocuments-(all)/professional-practice-manual/informed-consent-for-anesthesiacare.pdf?sfvrsn=8a0049b1_6.

Davis U. LGBTQIA Resource Center Glossary. Available at: https://lgbtqia.ucdavis.edu/educated/glossary. Accessed March 14, 2023.

Foronda C, Baptiste DL, Reinholdt MM, Ousman K. Cultural Humility: A Concept Analysis. J Transcult Nurs. May 2016;27(3):210-217.

Sexual Orientation and Gender Identity Definitions. Human Rights Campaign Available at: https://www.hrc.org/resources/sexual-orientation-and-gender-identity-terminologyand-definitions.

Health inequities and their causes. World Health Organization Available at: https://www.who.int/news-room/facts-in-pictures/detail/health-inequities-and-theircauses. Accessed March 14, 2023.

Eberl, T.J. Conscientious objection in healthcare. Theor Med Bioeth. 2019 Dec;40(6):483-486.

8 of 9 American Association of Nurse Anesthesiology 10275 West Higgins Road, Suite 500 | Rosemont, IL 60018 Professional Practice Division l 847-655-8870 l practice@aana.com

43.

Kulesa, R. A defense of conscientious objection: why health is integral to the permissibility of medical refusals. Bioethics. 2022 Jan;36(1):54-62.

Adopted by AANA Board of Directors October 2023

© Copyright 2023 9 of 9 American Association of Nurse Anesthesiology 10275 West Higgins Road, Suite 500 | Rosemont, IL 60018 Professional Practice Division l 847-655-8870 l practice@aana.com