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Perioperative Pain Management of Patients Presenting for Cardiac Surgery 357
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Perioperative Care of the LGBQTA+
Community
Olga C. Nin, Adam H. Fischler, Po-Yi Paul Su, Hamzah Adel Ramawad,
Kenneth Higgins Elliott III, and Dane Saksa
1 LGBTQA+ Historical Perspective, Current Status
and Future
Those who identify as lesbian, gay, bisexual, and transgender (LGBT) make up a
diverse community of individuals with a large population. The acronym LGBTQ+ is
commonly used in place of LGBT; in this instance the “Q” may refer to either queer
or questioning. The acronym is sometimes further expanded to include the intersex
community (“I”) as well as asexual individuals or allies (“A”). A “+” is commonly
included as a marker for those who also identify with this diverse community of indi-
viduals. This chapter will introduce the LGBTQ+ community, share some historical
perspective, discuss preoperative considerations for transgender care, review types of
gender affirmation surgery, and provide an overview of analgesia for this community
in the perioperative setting (including regional anesthesia).
O. C. Nin (
B
)
Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, USA
e-mail: onin@anest.ufl.edu
A. H. Fischler
Department of Anesthesiology, UCONN Health, Farmington, OR, USA
P.- Y. P. Su
Department of Anesthesia, University of California, San Francisco, USA
e-mail: paul.su@ucsf.edu
H. A. Ramawad
Department of Emergency Medicine, NYC Health & Hospital, South Brooklyn Health, Brooklyn,
USA
K. H. Elliott III · D. Saksa
UCLA Department of Anesthesiology and Perioperative Medicine, Los Angeles, USA
e-mail: kehiggins@mednet.ucla.edu
D. Saksa
e-mail: dsaksa@mednet.ucla.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
A. Abd-Elsayed and K. Schroeder (eds.), Perioperative Pain Management,
https://doi.org/10.1007/978-3-031-67648-2_23
359
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360 O. C. Nin et al.
Vocabulary and definitions are important in helping all patients feel comfortable,
safe, and respected by their care team. We therefore begin this chapter with a brief
discussion of terminology as it may apply to a patient on the day of surgery. Lesbians,
gay men, and bisexual men and women are defined by their sexual orientation, which
may be thought of in terms of an overlap of sexual attraction, behavior,and identity. In
contrast, transgender individuals identify in accordance with a gender identity and the
presentation of that gender identity. The transgender and gender diverse community
may also include individuals who reject the traditional male/female gender identity
dichotomy outright. The transgender and gender diverse community is diverse in
many facets including gender identity, gender expression, and sexual orientation.
Female-to-male transgender individuals are sometimes known as FtM, transgender
males, and transmen. Male-to-female transgender individuals might be known as
MtF, transgender females, and transwomen [1]. It can be helpful to confirm the
gender identity with which a patient identifies prior to the day of surgery so that
all members of the care team can address them with clarity and respect. While it is
difficult to get exact estimates of the size of the diverse LGBTQ+ population, most
current data suggests that around 3.5% of the United States population identify as
gay, lesbian, or bisexual [2]. Thus, at least 9 million individuals in the United States
identify as LGBTQ+ as of 2021 (though some surveys estimate millions more [3]).
Despite growing visibility and awareness of the LGBTQ+ community in the
United States, significant health disparities persist as a result of ongoing stigma,
prejudice, discrimination, and other critical determinants of health. From a soci-
etal perspective, LGBTQ+ individuals are subject to inequitable access to housing,
employment, and healthcare, which are well-known pillars of physical and mental
health. Due to prior negative experiences with healthcare, members of the LGBTQ+
community are sometimes reluctant to be forthcoming about aspects of their health,
further contributing to substandard access to healthcare resources. Furthermore,
LGBTQ+ patients have been shown to have increased rates of substance use disor-
ders, mental health disorders, and suicidal ideation. Beyond the realm of mental
health, research has also shown a higher burden of chronic disease within the
LGBTQ+ community,including increased incidence of cardiovascular risk factors [4,
5]. Additional research has demonstrated that LGBTQ+ youth experience increased
rates of adverse health outcomes (physical, mental, and behavioral) and that gender
minority youth may be at higher risk for being overweight or obese compared to
their cis-gender peers. Specifically, transgender and gender-diverse (TGD) patients
seeking gender-affirming care may face difficulty navigating the care system given
that perioperative teams may have less experience delivering sensitive, safe, and
evidence-based gender-affirming care. Clearly, much remains to be investigated on
the disparities experienced by LGBTQ+ patients in the perioperative setting [6].
Importantly, it is not just the patients we must care for in the perioperative arena.
We also can help protect the well-being of our LGBTQ+ healthcare professionals.
LGBTQ+ status was identified as an independent driver of anesthesiologist burnout,
one of four variables identified in a national survey of anesthesiologists [6]. Burnout is
correlated with decreased workplace efficacy, increased healthcare costs, and medical
errors [7]. Recognizing that burnout among healthcare professionals threatens all
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Perioperative Care of the LGBQTA+ Community 361
aspects of a functional U.S. health system, there have been major investments in
finding solutions to help our workforce feel more fulfilled, with a particular focus
on systems improvement. As of 2022, burnout has become such an epidemic within
medicine that organizations such as the National Academy of Medicine are calling
for collective action to address healthcare professional well-being via the National
Plan for Health Workforce Well-Being[8]. While more research is needed on the best
practices to mitigate LGBTQ+ healthcare professional burnout, energy and attention
spent on increasing perceived workplace support may mitigate the burnout of our
LGBTQ+ healthcare workforce and help our LGBTQ+ colleagues feel more fulfilled,
safe, and engaged. This can translate to a thriving LGBTQ+ workforce and result in
better care for our LGBTQ+ patients.
2 Preoperative Considerations
The goal of preoperative assessment is to reduce a patient’s perioperative morbidity
and mortality by identifying and optimizing risk factors related to the interactions
between the patient’s medical condition and surgical and anesthetic plans. While the
key biology relevant to preoperative assessment of anesthesia is the same across all
patients regardless of sexual orientation or gender identity, there are several peri-
operative nuances specific to the sexual and gender minority (SGM) population
that will be discussed in this section. Ever more importantly, SGM patients’ health
outcomes are disproportionally affected by pervasivesocioeconomic structural biases
and discrimination; thus, the preoperative assessment requires a non-judgmental,
patient-centered, compassionate approach.
Pregnancy Test
The American Society of Anesthesiologists (ASA) suggests “pregnancy testing may
be offered to female patients of childbearing age and for whom the results would alter
the patient’s management” [11]. This is based on reported incidence of 0.3% to 1.2%
of positive pregnancy in screening of biological females of childbearing potential.
However, in 100% of the cases of pregnancy the scheduled surgery was postponed,
cancelled, or had an impact on management. Additionally, these observational studies
suggest patient report is an unreliable marker for pregnancy, so further testing should
be offered. In retrospect, none of the studies specify SGM patients and are poorly
designed with inherent biases such as assuming “sexual activity” of a female is
exclusively with a sperm-producing partner [11, 12].
Interruption of hormone therapy in patients may result in ovulation; for example,
during the perioperative period. Therefore, it is aligned with the ASA to offer preg-
nancy tests to individuals capable of ovulation and for whom the results would alter
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362 O. C. Nin et al.
the patient’s management. However, no patients should be required to complete a
pregnancy test.
HIV+ Infection
The perioperative assessment of patients with positive HIV status is the same regard-
less of sexual orientation or gender identity. Because HIV and its treatment can have
multiorgan implications and HIV disproportionately affects the SGM population, it
is prudent to highlight the perioperative considerations for HIV-positive patients by
systems (Table 1)[13].
•
Undetectable viral loads are optimal for elective surgery. An HIV viral load test can
be used to monitor the efficacy of Antiretroviral therapy (ART), and CD4 count
is a proxy for immune constitution and function. For patients on stable ART,
HIV viral loads are reviewed every 4–6 months and CD4 counts are reviewed
every 12 months or optionally in certain circumstances [16]. If results within the
appropriate time frame are not available, consider ordering these laboratory tests.
Patients on ART therapy with HIV viral loads < 200 copies/ml and CD4 count
> 200 cells/mm3 (CDC HIV stages 1 or 2) had similar postsurgical outcomes as
HIV-negative patients. In contrast, patients with uncontrolled viral loads and low
CD4 counts (CD4 < 200 mm; CDC HIV stage 3) are associated with increased
risk of postoperative mortality and complications [17–20].
•
These patients could benefit from HIV specialists formulating an individual-
ized plan balancing the HIV treatment and delaying surgery. Additionally, viral
suppression minimizes the risk of nosocomial transmission [21, 22].
ARTs and opportunistic infection prophylaxis should be continued throughout the
perioperative period [23]. Cessation of ART can result in rapid viral load rebound
or immune decompensation [24–26]. Patients should be instructed to bring their
ART medications to the hospital in case of formulary discrepancies. Healthcare
providers should consult with HIV specialists if ARTs and OI prophylaxis cannot
be continued and to consider implications for ART resistance patterns, as well as
alternative replacements including liquid formulations, crushing compatible ARTs,
or intravenous formulations.
Multiple ARTs are simultaneously used in order to target multiple critical stages
of the HIV viral replication. Various ARTs may have anesthetic implications because
of potential adverse effects and/or due to potential interactions with anesthetic
medications. The commonly prescribed ARTs are summarized in Table 2.
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Perioperative Care of the LGBQTA+ Community 363
Table 1 Multisystemic manifestations of HIV and associated treatments and considerations for
perioperative care [14, 15]
Organ system Common effects Notes Perioperative considerations
Cardiovascular Myocarditis
Pulmonary hypertension
Accelerated coronary artery
disease/cardiac infarction
Pericardial effusion
Vasculitis
Heart failure/cardiomyopathy
Can be due to
HIV infection
itself, ARV,
and/or as a
consequence
of infections
Consider ECG and/or
further cardiac testing
(echocardiogram) in
patients with positive
cardiac review of systems or
physical exam
Pulmonary Opportunistic upper and lower
respiratory infections
High clinical
suspicion for
opportunistic
infection risks
with CD4
counts < 200
mm
3
Gastrointestinal Dysphagia (due to pharyngitis,
esophagitis, gastritis)
Esophageal reflux
Diarrhea
Nausea/vomiting
Hepatitis
Biliary disease
Severity of
upper GI
symptoms can
impact
aspiration risk
with general
anesthesia
Nausea and
diarrhea can
affect
electrolyte and
acid/base
abnormalities
Risk of hepatic
dysfunction
increased with
ARVs and
pre-existing
hepatic
dysfunction
Consider BMP to evaluate
for electrolyte abnormalities
Consider LFT and
coagulation assays for liver
dysfunction
ARV medications should be
continued during the
perioperative period
(“Perioperative Care in
Adults With HIV,” n.d.)
Renal Chronic kidney disease Nephrotoxicity
can be related
to ARV or
from HIV
infection
Consider assessment of
renal function
Adjust anesthetic for
patients with renal disease.
May need to renally adjust
certain ARVs if renal
function changes
postoperatively
(continued)
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364 O. C. Nin et al.
Table 1 (continued)
Organ system Common effects Notes Perioperative considerations
Neurologic Neurocognitive impairment
Opportunistic infections
(encephalitis, meningitis)
Seizures
Demyelinating and degenerative
disorders
Cranial and peripheral
neuropathy
Patients may be more
sensitive to opioids and
benzodiazepines due to
drug-drug interactions from
ARV and/or underlying
neurologic involvement
Intracranial masses or
opportunistic infections
may increase intracranial
pressure
Preexisting peripheral
neuropathy may impact the
risks and benefits of
regional anesthesia
Hematologic Thrombocytopenia
Anemia
Neutropenia
Coagulopathy
Lymphadenopathy
Malignancies
ARVs can also
induce
pancytopenia
Consider CBC (with
differential)
Endocrine Lipid dystrophy
Metabolic syndrome
Lactic acidosis
Hypothalamic–pituitary–adrenal
axis dysfunction (Cushing’s,
adrenal insufficiency)
Hyper/hypothyroidism
SIADH
Common side
effects from
ARVs
Consider BMP to evaluate
for electrolyte disturbances
Consider glucose testing
(A1C)
Consider adrenal and
thyroid function tests as
needed. Patients with
adrenal insufficiency may
need glucocorticoids
LFT liver function test, SIADH syndrome of inappropriate anti-diuretic hormone secretion, BMP
basic metabolic panel, ARV Antiretroviral medications
Hormone Therapy
Transgender patients may be on hormone therapy for medical management of gender
dysphoria (Table 3)[28–30].
Transgender females. Hormone therapy typically consists of estrogen and androgen
blockers. Estrogen is available as the naturally occurring 17-beta estradiol (available
as transdermal or injection preparations) or the synthetic analog ethinyl estradiol
(orally available since it avoids first-pass metabolism). Estrogen increases prothrom-
botic factors [31]; oral ethinyl estradiol is associated with increased thrombotic risk
and is not recommended for transgender patients [32]. Transdermal estrogen may
be the least thrombogenic in transgender females [33]. Other risks associated with
estrogen therapy include elevated cardiovascular/cerebrovascular risk and impaired
lipid and glucose metabolism. The World Professional Association for Transgender
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Perioperative Care of the LGBQTA+ Community 365
Table 2 Different antiretroviral therapy medications for the treatment of HIV and their possible
anesthetic considerations [21, 22, 27]
Drug class Medications Common adverse
effects
Anesthetic considerations
Nucleosides
analog reverse
transcriptase
inhibitor
– Inhibit reverse
transcription
by binding to
viral DNA
Abacavir
Adefovir
Didanosine
Emtricitabine
Lamivudine
Stavudine
Tenofovir
Zidovudine
Peripheral neuropathy
Pancytopenia
GI disturbances
(nausea/vomiting)
Consider BMP for electrolyte
abnormalities; some medications
(lamivudine, tenofovir, etc.) depend
on renal clearance and may require
dose reduction if kidney function is
impaired postoperatively
Consider CBC for anemia and
thrombocytopenia; risk of bleeding
with neuraxial anesthesia
(Zidovudine)
Implicated in lactic acidosis.
Consider avoiding prolonged
propofol infusion
Does not interact with cytochrome
P450 systems. Few significant
drug-drug interactions
Nonnucleoside
reverse
transcriptase
inhibitor
– Inhibits
reverse
transcription
by inhibiting
the reverse
transciptase
enzyme
Delavirdine
Doravirine
Efavirenz
Nevirapine
Rilpivirine
Skin rash/
Stevens-Johnson’s
Syndrome
GI disturbances
Consider BMP for electrolyte
abnormalities
Induces CYP3A4 (decreases serum
levels of midazolam, fentanyl,
oxycodone, hydrocodone, tramadol)
Consider ECG. May prolong QT
interval when administered with
other QT-prolonging medications
Protease
inhibitors
– Inhibit HIV
protease
Amprenavir
Atazanavir
Darunavir
Fosamprenavir
Indinavir
Nelfinavir
Ritonavir
Saquinavir
Tipranavir
GI disturbances
Hyperglycemia
Peripheral neuropathy
Hypertriglyceridemia
Elevated liver
enzymes
Consider BMP, LFT
Consider ECG, drug-drug
interactions with calcium channel
blockers and beta-blockers to
prolong PR interval. Risk of QT
prolongation with other
QT-prolonging medications
(sevofluorane, ondansetron,
prochlorperazine, promethazine,
droperidol)
Inhibits CYP3A4 (enhances effects
of midazolam and fentanyl,
oxycodone, hydrocodone,
tramadol.)
(continued)
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366 O. C. Nin et al.
Table 2 (continued)
Drug class Medications Common adverse
effects
Anesthetic considerations
Integrase
inhibitor
–Prevents
integration of
viral genome
into host
genome by
inhibiting
integrase
enzyme
Cabotegravir
Dolutegravir
Elvitegravir
Raltegravir
GI disturbances Consider BMP
CD4 entry
inhibitor
–Prevents
binding of
HIV virus to
CD4 cells
Enfuvirtide
Fostemsavir
Maraviroc
GI disturbances Consider BMP
BMP basic metabolic panel (including creatinine clearance), CBC complete blood count, ECG
electrocardiogram, LFT liver function test
Health recommends continuing estrogen hormone therapy through the periopera-
tive period unless specific risk factors such as smoking, family history or previous
history of thromboembolic events, or the use of synthetic estrogen preparations are
present. Withdrawal symptoms from estrogen include anxiety, depression, autonomic
dysfunction, and decreased seizure threshold [28]. Androgen blocking medications
function to reduce testosterone levels or activity, thus minimizing masculine charac-
teristics and helping decrease the estrogen dose. Common androgen blocks include
spironolactone, cyproterone (not available in the US due to concerns for hepato-
toxicity), and finasteride. Spironolactone also is a potent mineralocorticoid receptor
blocker and exerts antihypertensive and diuretic functions. Spironolactone may be
continued or stopped perioperatively to achieve the desired blood pressure and/or
volume status on a case-by-case basis but the anesthesia provider should be aware of
the implications on hemodynamics with anesthesia and effects on electrolytes (e.g.,
the potential for hyperkalemia).
Transgender males. Testosterone is the hormone therapy for transgender males.
There is no increased thromboembolic risk as is seen with estrogen and it can be
safely continued throughout the perioperative period. Testosterone may lead to an
increase in hematocrit and inflammatory markers but otherwise has minimal impact
on the delivery of anesthesia [23, 29, 30, 34, 35].
Little is known about the impact of hormone therapy on reference values of
laboratory tests [36]. A common approach assumes that laboratory tests reflect the
hormone profile; thus, for patients on chronic hormone therapy (> 6 months) the
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Perioperative Care of the LGBQTA+ Community 367
Table 3 Commonly used gender-affirming hormone therapy and their perioperative implications
[28–30]
Medication
class
Medications Notes Anesthetic considerations
Estrogen Oral estradiol is
associated with
increased
thromboembolic risk:
not recommended
Estrogen is associated
with coronary artery
disease,
cerebrovascular
disease, and impaired
lipid and glucose
metabolism
Generally, continue estrogen
perioperatively. Joint decision
making if other
thromboembolic risks such as
smoking and/or history of
VTE
Consider further cardiac and
metabolic assessment based
on history and physical
examination results
Androgen
Blocker
Spironolactone
Cyproterone acetate
Gonadotropin-release
hormone receptor
5-alpha reductase
inhibitor (finasteride)
Cytoproterone acetate
is not available in the
US due to concerns of
hepatotoxicity
Consider BMP to assess
electrolyte abnormalities
(potassium specifically) with
spironolactone
Spironolactone can be safely
stopped or continued to target
desired volume status/blood
pressure perioperatively
Testosterone Parental
(subcutaneous,
intramuscular)
Transdermal (gel,
cream, patch)
Testosterone leads to
menstrual cessation but
the time to cessation is
individually variable
Little correlation to
testosterone dose
(Ahmad and Leinung,
2017)
Safe to continue
perioperatively; no increased
thromboembolic risk
May increase hematocrit
count
Consider voluntary pregnancy
test in childbearing-patients
(± those who are sexually
active with sperm-producing
partners)
VTE Venous Thromboembolism
reference value to interpret laboratory tests should reflect their cisgender counter-
parts (i.e., transgender male should be referenced to cisgender males). There are
tools to help guide health care providers in interpreting some laboratory tests, but
ultimately anesthesia providers must exercise clinical judgement when assessing
abnormal laboratory values [37].
Gender-Affirming Interventions with Anesthetic Implications
Anesthesia providers need to recognize that gender-affirming interventions may alter
the relevant anatomy and mislead conventional physical examination interpretations.
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