Beyond the Binary: Considerations About Gender-affirming Care for the General Surgeon

A 65-year-old woman with a history of smoking presents to the hepatobiliary clinic for a solitary liver metastasis from a known gastric cancer. On review of her records, the patient is transgender and takes transdermal estradiol as hormone therapy. She additionally has undergone vaginoplasty in the past. Before the operation, the surgical resident contacts the Plastic Surgery team to discuss her previous vaginoplasty, possible differences in foley placement, and implications for laparoscopic surgery. Further, the resident contacts the patient’s primary care physician who prescribes her estrogen therapy for guidance regarding perioperative management. The resident, primary care physician, and patient discuss the risks and benefits of continuing her estrogen therapy in the setting of her increased thromboembolic risk with malignancy and surgery. Given her high Caprini score, the decision was made to hold her estrogen therapy in the perioperative period. She undergoes partial hepatec- tomy and recovers without incident. She restarted her estrogen therapy at discharge at the recommendation of her primary care provider.Like all patients, gender diverse individuals deserve access to general and emergency healthcare. Unfortunately, healthcare settings are prime locations where transgender and nonbinary (TGNB) people face discrimination, harassment, and refusal of care. 1 In the 2015 US Transgender survey, one quarter of respondents did not see a physician for fear of discrimination. 2 Moreover, many physicans who train and practice outside of settings with gender- affirming programs may not receive training on TGNB care or see many patients who openly identify as TGNB, which may make them uncomfortable. 3 As physicians, we have a responsibility to create a welcoming and respectful environment for all patients, regardless of gender identity. While special considerations for TGNB patients during acute trauma have previously been discussed, there remains a paucity of practical information and