The care of transgender patients in critical care: A call to action

Recent world events have further highlighted the social and legal disparities suffered by the LGBTQ+ community. Transgender people have been at the very centre of this discrimination, with their personal lives regularly thrust to forefront of public discussion. Being transgender is criminalised in 37 countries, only 97 countries allow people to legally change gender, and the UK government continues to ignore calls to ban so-called conversion therapy. ¹

Regardless of your personal views, it is vital that medical professionals continue to deliver the best care possible to all patients, irrespective of gender identity. Indeed, the General Medical Council mandates that all doctors must not unfairly discriminate patients by allowing personal views to affect the treatment we provide. ² The Royal College of Anaesthetists has joined the Royal College of Physicians’ ‘Inequalities in Health Alliance’ aiming to tackle some of the health inequalities that certain patient cohorts experience when they require healthcare. ³

Despite campaigns like this, 61% of transgender patients feel their specific healthcare needs are not understood. ⁴ Our recent survey on UK anaesthetists suggested it may be even more than this, with the median confidence regarding the perioperative care of transgender patients being 3/10. ⁵ As discussed in our recent review article in the journal, ⁶ many of the specific considerations for transgender patients are relevant to critical care (alterations to airway anatomy, cardiovascular and respiratory changes, the management of hormone therapy etc.), and it would therefore be logical to extrapolate that a similar knowledge gap exists in this domain. One of the most surprising findings from the survey were some of the responses from senior doctors, including: ‘I believe in biology not ideology’, ‘How would I opt out of treating a transgender patient’, and ‘I would refuse to treat a transgender patient undergoing elective surgery’. ⁵ Such discrimination is illegal under the Equality Act 2010. ⁷ These comments may represent the tip of a transphobic iceberg and highlight just how important it is to energise education for change.

Estimates of the number of openly transgender patients in the UK vary from 200,000 to 600,000, with numbers increasing year on year.^4,8 Whilst anaesthetising for gender-affirming surgery may remain largely the domain of specialist tertiary centres, the care of acutely unwell transgender patients does not. As with any patient, they may present at any time with any medical problem. The nature of critical illness means time is not always plentiful, and thus a baseline understanding of specific considerations is vital. For example, knowing that if a patient has undergone an endoscopic glottoplasty they may have a 33% smaller glottic aperture, and that those who have undergone cricothyroid approximation may have no cricothyroid membrane – not something you want to discover as you reach ‘Plan D’. ⁹ Similarly, whilst recognised international prescribing guidelines exist for hormone replacement therapy, through ignorance or unfounded concerns about side-effects, it is all too common for these drugs to be missed; in patients who have surgically transitioned, such abrupt discontinuation may lead to significant discontinuation symptoms as for any form of hormone replacement therapy. ¹⁰

Aside from the clinical implications, the social and nursing considerations are just as important. Critical care can be an intimidating and isolating place. The importance of the use of the correct pronouns can be easily overlooked. It is easy to do, and its benefits far outweigh any ‘awkwardness’ those not used to asking about them may feel. A simple ‘what are your preferred pronouns?’ can go a long way. Similarly, taking a trans woman’s grooming needs into consideration may prevent the distress associated with waking up after a period of sedation to discover what she considers to be a repulsive growth of facial hair. Consideration should also be given to transgender patients’ needs around using the toilet where their genitalia may not be what is ‘expected’ of their presenting gender. This is especially important given the current waiting times for NHS transgender care and waits of 4 years or more for a first appointment not out with the norm. ¹¹ This means that a patient may have completed social transition several years prior to their acute presentation but not received any medical or surgical treatment.

It is time the medical profession caught up with many other industries when it comes to the rights of our transgender patients. Specific management of transgender patients does not exist in any of the Faculty of Intensive Care Medicine’s, Royal College of Anaesthetists’, or Royal College of Physicians’ curriculums, and less than 50% of medical schools teach it as part of their core curriculum.^12–15 Small gestures have been made, including recent work by the Intensive Care Society, but much more still needs to be done. As critical care clinicians it is our duty to ensure our patients receive optimal and safe care when they are at their most vulnerable. Thus, it is time we gave patients of all gender identities the treatment and understanding they deserve.