Dear Editor, The review article ‘Challenges in provision of anesthesia to transgender patients in India: A scoping review’ by Singh et al.1 is highly relevant in today’s world. As awareness and acceptance of transgender people increase in our country, it is likely that requirement of anesthesia for gender affirmation and concomitant surgeries will increase. The article has described in detail the concerns in provision of health care to transgender and gender diverse individuals (TGDIs). Lack of comprehensive guidelines and experience limit safe perioperative care for these patients. Our center has been providing gender affirmation and other surgeries to TGDIs for the past 17 years. The World Professional Association of Transgender Health (WPATH) has delineated guidelines for the medical and surgical management of these individuals.2 TGDIs on estrogen therapy are at an increased risk of venous thromboembolism (VTE).3 As part of preoperative assessment, it is stopped prior to surgery. The recent WPATH guidelines do not suggest stopping estrogen.2 However, adequate prophylaxis for VTE is to be provided. High estrogen concentrations are known to lower serum albumin levels, thereby altering drug availability. Antiandrogen spironolactone can cause renal and hepatic damage, raise serum potassium levels, and cause volume depletion which can lead to intraoperative hypotension.2 It is usually stopped a day prior to the surgery. Bicalutamide can alter coagulation profile and prolong QT interval. Testosterone therapy can lead to dyslipidemia, erythrocytosis, and hypertension. Risk of myocardial infarction has been reported to double in transgender men on testosterone therapy.4 Interaction of monoamine oxidase inhibitors and selective serotonin reuptake inhibitors with anesthesia drugs is well documented. During preoperative evaluation, intake of these medications should also be specifically asked for. In these individuals, airway anatomy is according to sex assigned at birth. A previous facial masculinization surgery can distort the anatomy and make airway management challenging. Similarly, surgery for feminization of voice is performed to shorten vocal cord length and decrease vocal cord mass and can be done endoscopically. Anesthesia for these surgeries is itself challenging and necessitates placement of smaller-sized tubes for anesthesia in the future. To conclude, as highlighted by Singh et al.1., awareness among about distinct challenges during the perioperative period and their solutions is essential for smooth conduct of anesthesia. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Hemlata Kapoor (Mon,) studied this question.