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368 O. C. Nin et al.
Chest binding. A nonsurgical intervention, chest binding flattens the female breast
tissue with garments or other materials around the chest wall. This intervention is
associated with negative outcomes including high incidence of pain (back, chest,
shoulder), and respiratory symptoms (ranging from shortness of breath to respira-
tory infections) [38]. In fact, individuals who chronically practice chest binding had
abnormal forced spirometry values on pulmonary function testing [39]. The clinical
significance in the perioperative setting and interaction with anesthesia is not well
described; however, given the known pulmonary effects of general anesthesia (atelec-
tasis, ventilation-perfusion mismatch) anesthesia providers may consider suspending
chest binding during the perioperative setting.
Facial feminization. Facial feminization surgeries target the outward sexual char-
acteristics of the feminine face: a heart-shaped jaw, shorter forehead, small narrow
nose, arched eyebrows, prominent cheekbones, and fuller lips [40, 41]. Surgeries
of the lower face can have significant impacts on the patient’s airway. Mandibular
osteotomies and genioplasties to reduce chin width and height may create relative-
micrognathia and limit movement due to scarring. This may lead to a more chal-
lenging mask ventilation and tracheal intubation. Chondrolaryngoplasty to reduce
the size of the thyroid cartilage prominence (“Adam’s apple”) may affect cricothy-
rotomy in an airway emergency. In addition to cosmetic feminization, various vocal
cord feminization procedures have been described with a shared goal of elevating
the vocal pitch [40, 42]. This is significant for the anesthesia provider as the previous
surgery may increase the difficulty in selecting appropriately sized tracheal tubes and
performing endotracheal intubation; reciprocally, this increases the risk of injury to
the patient, such as tracheal stenosis and local tissue trauma during intubation [40].
Fascial masculinization. In contrast to facial feminization, facial masculinization
seeks to achieve characteristics of the male face: a square-shaped jaw,wider forehead,
wider nose and mouth, prominent supraorbital ridge, and facial hair [45]. The anes-
thetic considerations are similar to facial feminization surgeries, including postoper-
ative scarring limiting movement for mask ventilation and airway instrumentation or
distortion of surface landmarks for procedures (such as the cricothyroid membrane
for emergent cricothyrotomy). Lowering of the vocal pitch is often achieved with
testosterone therapy; laryngeal surgery for voice masculinization is rare but has been
described so anesthesia providers should be cognizant of previous laryngeal surg-
eries as an indicator for possible difficult endotracheal intubation and trauma [46,
47]. More relevantly, anesthesia providers need to be attentive to the anatomically
narrower female trachea despite the presence of surgically/hormonally masculinized
facial features. Tracheal stenosis may result from impaired regional perfusion due to
an oversized endotracheal tube or overinflated cuffs [48].
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Perioperative Care of the LGBQTA+ Community 369
3 Types of Gender Affirmation Surgery
Gender affirmation surgeries, also known as gender confirmation surgeries or gender
reassignment surgeries, have become increasingly recognized as a crucial aspect
of medical care for individuals who experience a mismatch between their gender
identity and their anatomy. With over 1.3 million adults in the U.S. identifying
as transgender, the importance of this type of medical care cannot be overstated.
These surgeries can involve a range of procedures, including genital reconstructions,
chest surgeries, facial feminization, or masculinization surgeries, in conjunction with
hormone replacement therapies. Despite its significant size, the transgender and
gender nonconfirming community continues to face significant challenges, including
discrimination, insurance exclusions, and lack of transgender health care education
by physicians, among others.
Gender affirmation medical care has presented challenging and exciting opportu-
nities f or growth since its beginning. The history of gender-affirming surgeries dates
to the early twentieth century, when Dr. Magnus Hirschfeld opened the Institute
for Sexual Science in Berlin, Germany. It was here that the first vaginoplasty was
performed for cisgender women with traumatic, congenital, and oncologic defects.
In 1966, Johns Hopkins University in Baltimore, Maryland, unveiled the first Gender
Identity Clinic to perform gender-affirming surgeries in the United States. Within its
initial 2–3 years, the clinic received nearly 2000 surgery requests [49]. This was a
groundbreaking moment in the history of gender affirmation surgeries as it demon-
strated the potential for medical intervention to alleviate the suffering of individuals
with gender dysphoria, a condition where a person experiences significant distress
due to the incongruence between their gender and their physical appearance [50].
Today, these surgeries continue to play a critical role in helping individuals achieve
gender congruence and live authentic, fulfilling lives.
For many transgender people, these surgeries are a crucial step in their journey to
live as their true selves and can bring immense physical and psychological benefits.
Individuals who underwent gender affirmation surgeries reported significant reduc-
tions in symptoms of depression, anxiety, and suicidality. In fact, gender affirmation
surgeries have been shown to decrease depression and suicidal tendencies compared
to those receiving hormone therapy alone [51]. This is further supported by a study
that showed that those who underwent one or more gender affirmation surgeries
had a 44% reduction of past-year suicidal ideation and psychological distress. Other
benefits include improvement in overall quality of life and physical health outcomes
[52].
Gender affirmation surgeries come in several forms and are performed by surgical
specialists in the fields of gynecology, urology, and plastic surgery. These surgical
interventions can be classified into a spectrum of procedures for those who were
assigned male at birth (AMAB) and those assigned female at birth (AFAB). As
expected, there are potential complications associated with gender-affirming surgery.
However, many of these are minor in nature and can be managed with outpa-
tient care. In fact, the incidence of complications is comparable to that of other
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370 O. C. Nin et al.
surgical procedures (i.e., non–gender-affirming surgeries) performed for unrelated
diagnoses [53] The complications related to transfeminine and transmasculine proce-
dures are summarized in Tables 4 and 5. Studies conducted on these procedures
consistently report a significant increase in overall body image, patient satisfaction,
and improvements in depression and anxiety [54].
Gender dysphoria can lead some transgender women to seek “bottom surgery” to
remove their penis. This complex surgical procedure typically involves several steps,
including penectomy, orchiectomy, vaginoplasty, clitoroplasty, and vulvoplasty. The
primary objective is to create a neovagina by inverting the penis. Along with the
standard surgical complications such as bleeding and infections, this procedure can
lead to complete or partial necrosis of the clitoris, labia, or vagina if blood supply is
interrupted. Transwomen who take hormone replacement therapy typically develop
Table 4 Transfeminine procedures
Transfeminine Procedures
LOS
Complications
Complication Rate
Pain Level
Breast augmentation
SD
Surgical complications: persistent breast pain,
infection, seroma/hematoma, skin necrosis,
superficial thrombophlebitis
Implant based complications: capsular
contracture, rupture of silicone, malposition,
breast implant illness.
Aesthetic concerns: breast asymmetry, skin
rippling
All cause a complication
rate of 1.8% [58]
MM + Reg
Thyroid cartilage reduction
SD
Common: odynophagia, hoarseness,
laryngospasm
20.3, 39.1, and 1.4%
respectively [59]
MM
Rare: infection, hematoma, laryngeal cutaneous
fistula, laryngeal edema, numbness of the larynx
or superior laryngeal nerve neuralgia
<1%
Brow reduction
SD
Numbness, eyebrow alopecia, asymmetry,
others
Others: hematoma, infection, eye-related
complication and sinus penetration
Open: alopecia (2.2%),
numbness (5.5%),
asymmetry (1.5%), others
(<1%)
MM
Endoscopic: alopecia
(2.8%), numbness (2%),
asymmetry (<1%), others
(<1%) [60]
Facial feminization
- Rhinoplasty
- Cheek augmentation
- Blepharoplasty
- Genioplasty
SD/HS
Dehiscence, infection, hematoma, epistaxis, PE
or DVT, ophthalmic injury, CSF leak, nerve
injury, and sinus fracture.
5.4, 5.1, 1.3, 2.1, 1.6, 2.5,
0.2, 0, and 0%
respectively
All cause a complication
rate of 5.4% [61, 62 ]
MM
- Mandibular angle
reduction
- Forehead contouring
Thyroplasty (“voice lift ”)
SD
Intraoperative vocal cord tear, hematoma,
laryngeal edema, aspiration pneumonia,
bleeding, dysphonia, dysphagia, and infection.
7% rate of wound
infection. 29% rate of
dysphonia and dysphagia
[63]
MM
Orchiectomy
HS
Bleeding, infection, hematoma, and ilioinguinal
nerve injury.
All cause complication
rate of 2.9% [64]
MM + Reg
Vaginoplasty
SD/HS
Surgical complication: bowel injury, vascular
injury, urologic injury, strictures, fistula, and
infections/bleeds.
Non-surgical complications: AKI, ileus,
bleeding, cardiac event, sepsis, and other
infections.
1.1, 0.1, 0.2, 3.2, 0.7 and
5.7% respectively.
MM + Reg
0.3, 5.25, 5.8, 2.5, 1.4,
and 1.8% respectively [65]
Vulvoplasty
SD
Bleeding, infection/abscess, swollen labia,
itching, and tissue necrosis.
Bleeding (1.8%), infection
(0.3%), and UTI (3.9%)
[66]
MM + Reg
Plastic Surgery, Urology, Gynecology, HS hospital stay, MM multimodal, Reg regional anesthesia, SD same day surgery
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Perioperative Care of the LGBQTA+ Community 371
Table 5 Transmasculine procedures
Transmasculine Procedures
LOS
Complications
Complication Rate
Pain Level
Mastectomy
HS
Bleeding/hematoma, partial nipple graft loss, full
nipple graft loss, seroma, infection, poor
aesthetic outcomes (scarring, contour
abnormalities)
12, 10, 3, 2, 1, and 13%
respectively
Up to 10% of patients
may need reoperation for
acute complications, with
bleeding and hematoma
being the most common
MM + Reg
All cause complication
rates of 10.4% [53]
Thyroid cartilage augmentation
(“Adam’s apple” enhancement)
SD
Sore throat, hoarseness, dysphagia, dysphonia
There is insufficient data
MM
Brow lift
SD
Alopecia, numbness, asymmetry, edema,
hematoma/infection/pain
2.8, 2, 0.7, 0.2, and 0.1%
respectively [60]
MM
Facial masculinization
- Rhinoplasty
- Forehead lightening
- Cheek augmentation
- Chin/jaw contouring
HS
Site infection, dehiscence, seroma
5, 3, and 3% respectively
[67]
MM
Thyroplasty (“Voice lift”)
SD
Intraoperative vocal cord tear, hematoma,
laryngeal edema, aspiration pneumonia,
bleeding, dysphonia, dysphagia, and infection
7% rate of wound
infection. 29% rate of
dysphonia and
dysphagia [63]
MM
Phalloplasty
- Free flaps
- Pedicled flaps
The following procedures are
typically performed in conjunction
with phalloplasty:
- Urethroplasty
- Glansplasty
- Scrotoplasty
HS
Donor site: decreased sensory function,
decreased motor function, delayed wound
healing, lymphedema, intractable pain
14, 11, 10, 1, 1, and 1%
respectively [68]
MM + Reg
Recipient Site (urinary): urethral stricture,
uretherocuteneous fistula, delayed wound
healing, hematoma, seroma, incontinence,
abscess, complete flap loss
32, 36, 12, 13, 12, 1, 1,
and 3% respectively.
Rate of operative
revision as high as 25%
[68]
Metoidioplasty
HS
Urethral stricture, uretherocuteneous fistula,
delayed wound healing, hematoma, seroma,
incontinence, abscess, decreased sensory
function, decreased motor function
21, 41, 10, 22, 0, 0, 3, 6
and 16% respectively
[68]
MM + Reg
Penis allotransplantation
HS
Infection, organ rejection, organ failure (loss of
sensory and motor function)
Insufficient published
data
MM + Reg
Hysterectomy
- Abdominal
- Vaginal
- Laparoscopic
HS
Dehiscence, surgical site infection, bleeding that
requires transfusion, PE, DVT, UTI, sepsis
All cause complication of
3.6%
MM + Reg
Vaginectomy
Bleeding, infections, bladder injury, rectal
perforation, urethral stricture, fistulas, voiding
dysfunction
Insufficient published
data
Oophorectomy
SD/HS
Bleeding, urinary tract injury, nerve injury,
infection
All cause complication
rates of 3.1% [57]
MM + Reg
Plastic Surgery, Urology, Gynecology, HS hospital stay, MM multimodal, Reg regional anesthesia, SD same day surgery
breast tissue, and many are content with the outcomes after 12–18 months [55].
However, some choose to undergo breast augmentation to increase their breast size,
which carries the standard risk associated with such procedures, such as infections,
bleeding, breast pain, and capsular contractures. To achieve a more feminine facial
appearance, many transwomen opt for procedures such as eyebrow reduction, thyroid
cartilage reduction, rhinoplasty, forehead contouring, and cheek augmentation. The
complications related to transfeminine procedures are summarized in Table 4.
Transgender men have different options for gender-affirming surgery such as
metoidioplasty, which creates a small phallus for standing urination but not pene-
trative intercourse. Some patients subsequently undergo phalloplasty. This refers
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372 O. C. Nin et al.
to the creation of a penis with a free flap of skin from the arm or thigh which
is then gradated onto the base of the clitoris to retain erotic sensation. Complica-
tions can include urinary tract stenosis, fistulas, phallus necrosis, and rectal injuries.
Mastectomy or “top surgery” is the most common procedure for transmasculine
individuals. It involves removing breast tissue and contouring the chest to create a
more masculine appearance. Nipple retention is often possible, and various tech-
niques are used depending on factors such as breast size and skin elasticity. Up to
10% of patients may need reoperation for acute complications, with bleeding and
hematoma being the most common [53]. Hysterectomy with bilateral oophorectomy
is also a common procedure for many transmen, but some may choose to preserve
the option of pregnancy. The incidence of perioperative complications associated
with hysterectomy and oophorectomy performed for gender-affirming surgery is the
same for cisgender women undergoing the same procedures [56]. The complications
related to transmasculine procedures are summarized in Table 5.
Multidisciplinary pain medicine plays a crucial role in these surgeries by helping to
manage postoperative pain and discomfort and in some cases chronic pain syndromes.
After a gender affirmation procedure, patients may experience pain and discomfort
due to the incisions, tissue manipulation, and healing process. Pain management helps
patients recover more comfortably and quickly, allowing them to return to their daily
activities. Pain medicine can be administered through various methods such as oral
medications, topical creams, peripheral nerve blocks, and epidural injections. The
choice of pain management methods will depend on the type of procedure, patients’
preferences, allergies, and the primary surgeon’s recommendation. Physical therapy
and rehabilitation programs can also be effective in managing pain after gender-
affirming surgery and some patients may benefit from therapy to help them cope with
chronic pain and improve their quality of life [57]. Ultimately, the best approach
to pain management after gender-affirming surgery will depend on the individual
patient’s needs, preferences, and underlying health conditions.
4 Anesthesia Care for Sex Reassignment Surgery
Gender-affirming surgeries (GAS) can be divided into cosmetic surgery, “top” or
“chest” surgery (mastectomy, breast implants), and “bottom” or “genital” surgery
(vaginoplasty, penectomy, orchiectomy, phalloplasty, metoidioplasty, scrotoplasty).
Some female-to-male transgender individuals may also wish to have hysterectomies,
salpingectomies, and vaginectomies. Sex reassignment surgery (SRS), also referred
to as genital affirmation surgery, is a category within the more general umbrella of
GAS. SRS encompasses the more complex and irreversible interventions of gender-
affirming surgeries and is becoming more common for the transgender community
as awareness and acceptance has increased over recent years. While the “top” SRSs
for transgender patients require little to no change in the intraoperative anesthetic
management from that of cisgender individuals, the “bottom” SRSs are specific to
transgender patients and require interesting options for optimal anesthetic and pain
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Perioperative Care of the LGBQTA+ Community 373
management outcomes. Therefore, the focus of the intraoperative material found later
in this section will describe the anesthetic management of the transgender patient
undergoing “bottom” or “genital” sex reassignment surgery. Collaboration and agree-
ment with surgical colleagues regarding the anesthetic management of these cases
is essential.
It is important to understand that there are many recommended safeguards
preceding gender-affirming s urgeries. The World Professional Association for Trans-
gender Health (WPATH) Standards of Care Version 8 proposes many guidelines,
including the necessity for a documented history of gender dysphoria with associ-
ated psychological evaluation before starting any component of gender transition
[54]. Transgender patients of all ages undergo extensive preoperative evaluation,
including mental health screenings, before any proposed surgical procedures and are
typically required to be socially transitioned and receiving gender-affirming hormone
therapy (GAHT) for at least one year. It is r ecommended that these patients have one
mental health provider referral for chest/breast surgery and two independent referrals
before “bottom” surgery. Despite recommendations, final decisions remain with the
patient, parents (as applicable), surgeons, mental health providers, and other involved
providers.
General Preoperative Considerations for Transgender Patients
Presenting for Gender-Affirming Surgery
First things first: it is of the utmost importance that providers understand and are
comfortable using preferred pronouns when interacting with transgender patients.
Utilizing the transgender patient’s preferred name and pronouns is one of the
most powerful tools for making the transgender patient feel understood, accepted,
respected, and safe. The most common pronouns are he/him/his, she/her/hers/ and
they/them/theirs. Providers should introduce themselves with their preferred name
and pronouns. The provider can then request the patient to reveal their preferred name
and pronouns. For example: “Hello, my name is Dr. Smith; I use he/him pronouns.
What are your preferred pronouns and name?” There is no better way to initiate an
encounter with a member of the transgender community. Electronic medical records
(EMRs) should be designed to identify every patient’s assigned sex at birth, legal
name, gender identity, and preferred name. This will help providers when caring for
transgender patients and prevent unnecessary confusion or mislabeling of gender.
Given the high incidence of mental illness in t ransgender patients, a complete
understanding of the impact of various psychiatric medications is essential in the
care of these patients. This is no different than the care of cisgender patients with
mental illness. Anxiety, depression, and suicide ideation are frequent psychiatric
diagnoses amongst transgender individuals and should be recognized and managed
perioperatively. These patients are also more likely to have nicotine and substance
use disorders compared to the general population [69]. Anxiety will likely be at
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374 O. C. Nin et al.
its highest level given the significance of the surgery these patients are undertaking.
Optimization of psychiatric medications and control of substance use disorders by the
patient’s mental health provider in conjunction with the provision of a comfortable
and low stress preoperative environment is the best approach.
Most if not all transgender patients presenting for GAS will be receiving GAHT.
The medications most commonly utilized include testosterone and estrogen. Spirono-
lactone is also commonly used for transgender females for the purpose of blocking the
effects of testosterone. While there may be concern regarding a potential increased
risk of venous thromboembolism (VTE) in transgender female patients taking
estrogen, there is no clear evidence supporting discontinuation of estrogen therapy
prior to GAS. WPATH recommends continuation of estrogen therapy before and
after surgical procedures in transgender females without additional risk factors such
as smoking, family history of venous thromboembolism, or the use of synthetic
estrogens such as ethinyl estradiol, which is no longer recommended [28, 70].
Additionally, the use of transdermal estrogen as opposed to oral estrogen seems
to have lower risk of VTE and should be considered the best option, especially
perioperatively. Regarding transgender male patients, there appears to be no need
to routinely discontinue testosterone prior to GAS. A systematic review did not
demonstrate any increased association between venous thromboembolism and peri-
operative testosterone use [34, 35]. Spironolactone has its own intrinsic risks of
hyperkalemia and acute kidney injury (AKI) that should be no different in trans-
gender patients versus cisgender patients. A placebo-controlled randomized trial
showed no increased risk of kidney injury in the spironolactone group [71]. Intraop-
erative concerns regarding hypovolemia and hypotension from the diuretic effects of
spironolactone are appropriate.
An occasionally pertinent issue that may arise involves risk stratification models
for transgender patients. These assessments have the potential to be impacted due
to the common inclusion of a binary sex component in the scoring systems. Since
the male sex is usually scored higher, there is a chance of underestimating risk in
transgender females or overestimating risk in transgender males. Since it remains
unclear which sex component is most appropriate to incorporate in various risk
stratification models for transgender patients, it may be best to calculate both options
and comply with the one indicating higher risk.
Providers should assess for any previous cosmetic gender-affirming surgeries that
the transgender patient may have undergone. Facial feminization and masculinization
procedures can potentially impact airway anatomy which may create difficulty with
intubation or ventilation. Vocal feminization procedures in transgender females may
involve anterior (Wendler) glottoplasty, also referred to as anterior commissure web
formation, and cricothyroid approximation ( CTA). Both of these procedures may
affect the glottic opening which could require the need for a smaller endotracheal
tube [72]. Also, these procedures may have the additional complications of vocal
cord dysfunction, lesions, or paralysis.
When considering preoperative laboratory tests, it is important to consider the
appropriateness of a preoperative pregnancy test in transgender males. Given that
fertility is inconsistently impacted by testosterone therapy, transgender males with
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Perioperative Care of the LGBQTA+ Community 375
intact female reproductive organs have the potential to become pregnant. Therefore,
without absolute knowledge of sexual relations, providers should consider obtaining
a pregnancy test on all transgender males of reproductive age.
It is important to recognize that some laboratory tests may seem inconsistent with
the transgender patient’s affirmed gender. In those cases, the provider must consider
the patient’s sex at birth. Providers should also be aware that the opposite scenario
is possible where typical reference values for various laboratory tests may not apply
when considering sex assigned at birth instead of the patient’s affirmed gender [73].
Transgender patients on GAHT can have changes in lab values that begin to shift
toward the reference values of their affirmed gender by 6 months of therapy [74]
Changes include increases in hematocrit, hemoglobin, and creatinine for patients
taking testosterone and decreases in these values for those taking estrogen.
Another preoperative consideration specific to transgender males is the practice of
chest binding. This process involves using specialized garments to compress breast
tissue in order to create a flat chest and therefore appear more male. This behavior
helps to reduce the dysphoria related to their physical appearance and allows them
to feel more like their affirmed gender [75]. However, the resultant restriction of
breathing can produce shortness of breath with associated reduced exercise toler-
ance and speech difficulties [76]. Skin damage can become an issue as well. Chronic
binding has been shown to result in abnormal baseline lung function including an
overall reduction in lung volumes, abnormally high FEV1/FVC, lower peak expira-
tory flow values, and decreases in expiratory vital capacities (both slow vital capacity
and forced vital capacity) [76, 77]. Given these findings, patients may be at risk of
restrictive lung disease over the long term but very likely will have some degree of
atelectasis while engaging in chest binding, which could affect the patient’s oxygena-
tion during the perioperative period [77]. Providers should have a plan in place for
preoperative discontinuation of chest binding as well as postoperative resumption if
desired by the patient. One consideration would be having patients refrain from chest
binding for 24 h preoperatively and resume no sooner than 24 h after ambulation.
Providers could also require that patients perform incentive spirometry before and
after anesthesia [77].
General Logistics Regarding “Bottom” Sex Reassignment
Surgery
In general, the “bottom” sex reassignment surgeries take 2 to 6 h depending on which
surgeries are undertaken. Most commonly, the postoperative management requires
a 3 to 4 day hospitalization. Postoperative ambulation does not usually occur before
postoperative day (POD) #2 in many circumstances.
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Preoperative Analgesic and Anxiolytic Medications
Sex reassignment surgery, or genital affirmation surgery, is not just generic recon-
structive surgery. It also involves the rearrangement of some particularly crucial
nerves, some of which are responsible for sexual arousal and pleasure. These sensory
nerves are sometimes severed and transported to new locations. Due to this, neuro-
pathic pain is quite common and can be quite uncomfortable and confusing to patients
in the postoperative period. Therefore, gabapentinoids should be considered for opti-
mization of pain management. Although most current literature does not indicate a
meaningful benefit to using these medications as adjuncts in treating general post-
surgical pain, the neuropathic pain and occasional phantom sensations experienced
by gender reassignment surgery patients warrant consideration of the use of these
medications. Since these patients are typically not elderly, the risks of dizziness and
sedation should be low [78]. One important caveat would be to obtain clearance to
use these medications from the patient’s mental health provider in order to assure
that the gabapentinoids will not adversely interact with the patient’s other psychiatric
medications.
Other preoperative analgesic medications such as acetaminophen and celecoxib
can be given orally prior to surgery with a sip of water. Alternatively, the anes-
thesia provider could administer intravenous acetaminophen and ketorolac along
with dexamethasone during the intraoperative phase of care.
Another important preoperative consideration is the management of patient
anxiety, as this is a common preexisting condition in transgender patients. Sex
reassignment surgery is an enormous undertaking for what are typically young or
middle-aged individuals. These patients are having parts of the body that they have
known for their entire lives permanently removed or revised. There really is no going
back. Midazolam should be effective along with an abundance of compassion and
support. When these patients feel safe and respected, anxiety and fear should be
greatly reduced.
Intraoperative Anesthetic Plan
The intraoperative phase of care is open to many options, but should be paired with
an effective postoperative pain management plan. There is a lack of randomized
controlled trials comparing the effectiveness of various anesthetic and pain manage-
ment approaches to the care of transgender patients undergoing SRS. Therefore, anes-
thesia providers must rely on their knowledge and experience with similar surgical
procedures in order to formulate an appropriate and successful anesthetic plan. While
many anesthetic plans could be formulated, the following are three anesthetic plans
for sex reassignment surgery that should be considered.
1. Combined spinal/epidural followed by general anesthesia
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Perioperative Care of the LGBQTA+ Community 377
After appropriate sedation is given and monitoring applied, a combined spinal/
epidural (CSE) can be performed utilizing bupivacaine and fentanyl in the spinal
component of this technique. Following a test dose to rule out an intravascular
epidural catheter, the patient can be placed in the supine position for induction of
general anesthesia. Total intravenous anesthesia (TIVA) with any combination of
preferred anesthetic drugs would be most desirable from a side effect and sustain-
ability standpoint. Low total fresh gas flow general anesthesia with sevoflurane is
also a reasonable choice as an adjunct to TIVA or on its own.
Postoperatively, an epidural infusion of bupivacaine/fentanyl or bupivacaine/
hydromorphone solutions can be initiated and maintained for analgesia. The local
anesthetic component has the additional benefit of producing a sympathectomy to
the lower body which may have a beneficial effect by virtue of improving circulation
to the newly created tissues and grafts.
Since many of these patients remain on bedrest through the first postoperative
day, this epidural infusion can continue. Once ambulation is to proceed , the epidural
solution can be switched to opioid only or it can be discontinued if desired by the
providers. This technique allows potential elimination of intravenous opioid usage
with its multiple associated risks and side effects. Nonopioid multimodal pain medi-
cations (acetaminophen, celecoxib, gabapentinoid, dexamethasone) can be continued
postoperatively along with oral opioids as needed.
2. Spinal anesthetic followed by general anesthesia
This is a similar initial plan to that described above; however, this technique will
likely require the use of an opioid patient-controlled analgesia (PCA) pump post-
operatively given the typical severity of postoperative pain once the effect of the
spinal anesthetic dissipates. If adding preservative-free morphine instead of fentanyl
to the bupivacaine spinal anesthetic, caution is advised when starting intravenous
opioid PCA in order to avoid delayed respiratory depression. Nonnarcotic multi-
modal medications (acetaminophen, celecoxib, gabapentinoid, dexamethasone) can
be continued postoperatively.
3. General anesthesia
This method will require the use of an opioid PCA pump postoperatively.Nonnarcotic
multimodal medications (acetaminophen, celecoxib, gabapentinoid, dexamethasone)
can be continued postoperatively.
Other intraoperative considerations include providing normotension and proper
hydration. It should be noted that the penectomy-orchiectomy-vaginoplasty combi-
nation surgery does require a bowel prep. Therefore, these patients are likely to be
more dehydrated then the average patient in the preoperative period. Also, if not given
preoperatively, anesthesia providers s hould give the usual multimodal nonnarcotic
analgesics and antiemetic medications that are typically given to the vast majority
of surgical patients during the intraoperative period.
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