Perhaps not surprisingly, I got a lot of email in response to the PAAD on the care of transgender youth. Here is a sample
From Nelson J. Aquino, MS, CRNA
Thank you both for the pediatric article of the day (and your post on gender-affirming surgery and mental health outcomes).
As you highlighted, transgender health, medical, surgical, and perioperative care are all vulnerable areas for any provider in today's climate.
"It is not our role to judge the gender identification of our patients and the role their families play in supporting transition. It is our role to educate ourselves about the vulnerability of this patient/family population and to accept and affirm their identity while providing perioperative care." This quote is a compelling statement, and this is what is the true message.
As pediatric anesthesia anesthesiologists/ CRNAs participating in the care of transgender children and youth, we have an opportunity to be an ally, decrease the stigma associated with TGNC people, and reduce the suicide rate for all sexually and gender diverse youth. For example, in the 2019 Centers for Disease Control and Prevention Youth Risk Behavior Surveillance Survey, a 40% decrease in suicidal attempts was described in sexually and gender diverse youth who reported having at least one accepting adult in their lives (National Survey on LGBTQ Mental Health, 2020).
When colleagues ask me what to do if they make a mistake with pronouns in the perioperative environment or we get complaints about staff, I offer this:
When caring for gender-diverse patients, a perioperative team huddle is recommended to discuss potential issues with misgendering and how to facilitate best a safe and respectful operating room check-in and time-out procedure. It is not uncommon to use the incorrect pronoun or gender identity. When faced with an uncomfortable conversation, self-regulation and accountability for unintentional harm is the best resolution. If you find yourself mistakenly calling a patient by their wrong pronoun or name, take a minute to pause, apologize, and move forward with your interview using the affirmed pronoun. Respectful acceptance and being nonjudgmental foster a milieu of trust. Contrarily, saying "I know someone who is transgender" or repeating "I am sorry" is a form of culpability. Allow mistakes to be a basis for cultural humility and personal growth (Aquino et al., 2021).
Our specialty anesthesia team, the Gender Affirming Surgical Perioperative Program (GASPP), is proud to offer a gender affirmation model of perioperative care that fulfills the purpose of supporting our institution's mission of comprehensive and affirming health equity for all. Furthermore, this "Pediatric Article of Today" embodies the professional impact and societal responsibility to support transgender and gender diverse youth in the gender in which they identify.
I have attached some articles written by myself and colleagues that I hope you share with our pediatric anesthesia colleagues to advance the care for transgender patients in the perioperative environment. In addition, I hope the work the GASPP team has done will empower our pediatric anesthesia colleagues to create programs like ours to support their patients and families.
Timely, I had a zoom with Travis and Remy (both from SPA), and we are brainstorming ideas for future collaborations.
Thank you again for your time and reading my response.
Aquino, N.J.; Boskey, E.R.; Staffa, S.J.; Ganor, O.; Crest, A.W.; Gemmill, K.V.; Cravero, J.P.; Vlassakova, B. A Single Center Case Series of Gender-Affirming Surgeries and the Evolution of a Specialty Anesthesia Team. J. Clin. Med. 2022, 11, 1943. https://doi.org/10.3390/jcm11071943
Aquino, Nelson J. MS, CRNA; Ganor, Oren MD; Chrisos, Haley A. PA-C; Oles, Norah BS; Boskey, Elizabeth R. PhD, MPH, LICSW Perioperative Issues With Gender-Diverse Youth, Journal of Pediatric Surgical Nursing: 1/3 2021 - Volume 10 - Issue 1 - p 23-31 doi: 10.1097/JPS.0000000000000282
Boskey, E. R., Johnson, J. A., Harrison, C., Marron, J. M., Abecassis, L., Scobie-Carroll, A., Willard, J., Diamond, D. A., Taghinia, A. H., & Ganor, O. (2019). Ethical Issues Considered When Establishing a Pediatrics Gender Surgery Center. Pediatrics, 143(6), e20183053. https://doi.org/10.1542/peds.2018-3053
Discepolo K, Aquino N. Considerations for Transgender Patients Requiring Dental Rehabilitation. J Dent Child (Chic). 2022 Jan 15;89(1):46-51. PMID: 35337400.
National Survey on LGBTQ Mental Health. (2020, September 6). The Trevor Project. https://www.thetrevorproject.org/survey-2019/?section=Methodology
Oles, N., Ganor, O., Aquino, N.J., & Boskey, E.R. (2020). Surgical Affirmation for Gender-Diverse Youth. Journal of Pediatric Surgical Nursing.
From: Remigio A. Roque, M.D., D.ABA
I want to applaud the PAAD team for their inclusion of Dr. Gordon’s recent perspective piece that highlights the very tough situation being faced by physicians and other health professionals in Texas who care for transgender and non-binary youth. As the article’s title suggests, these practitioners are caught in the middle of an on-going legislative battle over access to gender-affirming care, simultaneously trying to navigate how to best take care of their patients’ physical and mental health while also risking criminal prosecution and liability, all while following currently accepted standards of care1,2. Taking care of and advocating for vulnerable patients is something pediatric anesthesiologists are used to, and I can only begin to imagine how these colleagues are feeling when their compassion and expertise are being questioned.
Unfortunately, Texas is not the only state where there are current legislative efforts to restrict access to gender-affirming care for youth. As of March 2022, 15 states had restricted access to care or were considering laws that would do so if passed 3-5. Some of these bills would also: classify gender-affirming care as child abuse, include penalties for parents who facilitate access to care for their own children, bar insurance providers from covering gender-affirming care, and make healthcare practitioners subject to criminal prosecution or disciplinary actions from state licensing boards. In these states, it is estimated that 58,000 youth and young adults would lose access to care5. Just as a comparison, about 70,000 children have appendicitis each year6.
There may be some who question the relevance of this to our specialty, but pediatric anesthesiologists are dedicated to providing the best care to children, and it is important that we answer the recent call of our society to educate ourselves about this vulnerable patient population7.
These youth are not just patients of pediatricians, endocrinologists, and mental health professionals. Gender-diverse children and adolescents are part of the perioperative patient community. Dr. Gordon’s piece cited the 2017 estimate of ~0.7% of adolescents identifying as transgender. This estimate likely underestimates the true numbers. Higher percentages (up to ~10%) have been observed in several studies since8,9. We WILL take care of these patients in our pain clinics, operating rooms, and ICUs. Much of the care provided may be outside the context of “gender-affirming care”, but we have a duty to make sure ALL the care we provide is gender-affirming.
At the very least, we can respect our patient’s chosen names and affirmed gender identities as Dr. Maxwell stated in her introduction to this article. These small actions should not be discounted. Trans youth who are able to use their chosen names and whose pronouns are respected have much lower rates of depression and suicidality10,11. Any reduction in suicidality is critical in a population where 30-50% have reported suicidal behaviors12.
Further, we can strive to learn about the applicable perioperative considerations for the population13 , stay abreast of the legislative trends in our states and others, and continue to support our colleagues who remain “caught in the middle”. Politics and personal beliefs aside, I think most of us would agree that medical decision-making should be informed by evidence-based guidelines and left to patients, families, and medical professionals – not politicians.
1. WPATH Standards of Care (version 7) International Journal of Transgenderism, 13(4), 165–232
2. Hembree WC, Cohen-Kettenis PT, Gooren L, et al. Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline [published correction appears in J Clin Endocrinol Metab. 2018 Feb 1;103(2):699] [published correction appears in J Clin Endocrinol Metab. 2018 Jul 1;103(7):2758-2759].
3. https://freedomforallamericans.org/legislative-tracker/medical-care-bans/ Accessed 5/17/22
4. https://www.lgbtmap.org/equality-maps/healthcare_laws_and_policies/youth_medical_care_bans Accessed 5/17/22
5. Prohibiting Gender-Affirming Medical Care for Youth Brief March 2022 https://williamsinstitute.law.ucla.edu/publications/bans-trans-youth-health-care/ Accessed 5/17/22)
6. https://www.sages.org/wiki/pediatric-appendicitis/ (Accessed 5/17/22)
7. https://pedsanesthesia.org/statement-on-transgender-care/ (Accessed 5/17/22)
8. Johns MM, Lowry R, Andrzejewski J, et al. Transgender Identity and Experiences of Violence Victimization, Substance Use, Suicide Risk, and Sexual Risk Behaviors Among High School Students — 19 States and Large Urban School Districts, 2017. MMWR Morb Mortal Wkly Rep 2019;68:67–71.
9. Kidd KM, Sequeira GM, Douglas C, et al. Prevalence of Gender-Diverse Youth in an Urban School District. Pediatrics. 2021;147(6):e2020049823.
10. Russell ST, Pollitt AM, Li G, Grossman AH. Chosen Name Use Is Linked to Reduced Depressive Symptoms, Suicidal Ideation, and Suicidal Behavior Among Transgender Youth. J Adolesc Health. 2018;63(4):503-505.
11. The Trevor Project. (2020). 2020 National Survey on LGBTQ Youth Mental Health. New York, New York: The Trevor Project.
12. Toomey RB, Syvertsen AK, Shramko M. Transgender Adolescent Suicide Behavior. Pediatrics. 2018;142(4):e20174218.
13. Roque RA. Transgender pediatric surgical patients-Important perioperative considerations. Paediatr Anaesth. 2020 May;30(5):520-528.
From Yashesh Savani, Lynne Martin and others
I support standing up to these states that are restricting care to our vulnerable youth, whether TGD or other groups. We can start by having the SPA and our other national anesthesia professional societies seriously consider not holding meetings/conferences in these states until their positions are reconsidered.