Critical Illness in Transgender Patients: A Comprehensive Review for the Intensivist

Dr Neeraj Manikath , claude.ai

Abstract

Background: Transgender individuals represent an estimated 0.6-1.4% of the population, yet their unique physiological and pharmacological considerations during critical illness remain poorly understood by critical care practitioners. This review addresses the specific challenges and evidence-based management strategies for transgender patients in the intensive care unit (ICU).

Objectives: To synthesize current evidence regarding critical care management of transgender patients, with particular focus on hormone-related complications, airway management challenges, and ICU protocols for gender-affirming therapy continuation.

Methods: Comprehensive literature review of PubMed, EMBASE, and Cochrane databases from 2000-2024, supplemented by expert consensus statements and clinical practice guidelines.

Results: Key considerations include increased venous thromboembolism (VTE) risk with gender-affirming hormones, unique airway challenges following facial masculinization surgery, and the critical need for individualized hormone management protocols during acute illness.

Conclusions: Transgender patients require specialized critical care approaches that balance acute illness management with continuation of gender-affirming care when clinically appropriate.

Keywords: Transgender, Critical Care, Gender-Affirming Hormones, Intensive Care Unit, Venous Thromboembolism

Introduction

The transgender population faces significant healthcare disparities, with studies demonstrating higher rates of emergency department visits and hospitalizations compared to cisgender individuals.¹ Critical care physicians increasingly encounter transgender patients, yet formal training and protocols for their care remain limited. This review provides evidence-based guidance for managing transgender patients in the ICU, addressing unique physiological considerations, pharmacological interactions, and cultural competency requirements.

The primary challenges in transgender critical care include: hormone-related thrombotic risks, surgical complication management, airway considerations post-facial surgery, and psychosocial factors affecting recovery. Understanding these complexities is essential for optimal patient outcomes.

Epidemiology and Demographics

Transgender individuals comprise approximately 1.4% of the U.S. population, with higher prevalence among younger demographics.² ICU admissions among transgender patients show distinct patterns:

Higher admission rates for surgical complications (particularly post-operative complications from gender-affirming surgeries)
Increased prevalence of mental health comorbidities requiring critical care intervention
Greater likelihood of delayed presentation due to healthcare avoidance
Higher rates of substance use disorders requiring acute management³

🔹 Clinical Pearl: Transgender patients may delay seeking care due to previous negative healthcare experiences. Early identification and culturally competent care can prevent progression to critical illness.

Gender-Affirming Hormone Therapy and Critical Illness

Hormone Types and Physiological Effects

Feminizing Hormones:

Estradiol (oral, transdermal, injectable)
Anti-androgens (spironolactone, cyproterone acetate, GnRH agonists)

Masculinizing Hormones:

Testosterone (intramuscular, topical, subcutaneous)

Cardiovascular and Thrombotic Considerations

Venous Thromboembolism Risk

Gender-affirming hormone therapy significantly alters VTE risk profiles:

Estrogen Therapy:

Risk Increase: 3-6 fold increased VTE risk⁴
Mechanism: Increased factor VII, VIII, and fibrinogen; decreased protein S
Peak Risk: First year of therapy, particularly with oral estrogen
Route Dependency: Transdermal estrogen shows lower VTE risk compared to oral formulations⁵

Testosterone Therapy:

Controversial Risk: Studies show conflicting results
Potential Mechanisms: Increased hematocrit, altered lipid profiles
Monitoring Required: Regular hematocrit assessment (target <54%)⁶

🔹 Clinical Pearl: Always obtain detailed hormone history including type, route, duration, and recent changes. Consider VTE prophylaxis earlier and more aggressively in estrogen-treated patients.

Critical Care Management of Hormone-Related VTE

Assessment Protocol:

Immediate anticoagulation if high clinical suspicion
CT pulmonary angiogram for PE evaluation
Duplex ultrasonography for DVT assessment
Consider hormone discontinuation during acute thrombotic event

Treatment Considerations:

Standard anticoagulation protocols apply
Duration: Extended therapy may be warranted given ongoing hormone use
Monitoring: Enhanced surveillance for bleeding complications

🔹 Oyster Alert: Don't assume all transgender patients are on hormones. Some may have discontinued therapy, never initiated treatment, or be using non-prescribed hormones.

Perioperative and Post-Surgical Critical Care

Gender-Affirming Surgery Complications

Vaginoplasty Complications:

Vaginal necrosis or dehiscence
Rectovaginal fistula
Severe pain management requirements
Urinary retention or complications

Phalloplasty/Metoidioplasty Complications:

Flap necrosis
Urethral complications
Donor site morbidity

Facial Feminization Surgery (FFS) Complications:

Significant facial edema
Nerve injury
Bleeding complications
Airway compromise

🔹 Critical Hack: For post-FFS patients, prepare for difficult airway management. Have fiber-optic bronchoscope readily available and consider awake intubation techniques.

Airway Management Post-Facial Masculinization/Feminization Surgery

Anatomical Considerations:

Altered facial anatomy from bone contouring
Significant perioperative edema affecting airway structures
Potential nerve injury affecting facial sensation
Modified jaw mobility from surgical intervention

Difficult Airway Algorithm Modifications:

Pre-assessment:
- Review surgical notes for specific procedures performed
- Assess degree of facial edema
- Evaluate mouth opening and neck mobility
Equipment Preparation:
- Fiber-optic bronchoscope (primary choice)
- Video laryngoscope with multiple blade sizes
- Supraglottic airway devices
- Surgical airway equipment immediately available
Technique Selection:
- First-line: Awake fiber-optic intubation
- Alternative: Video laryngoscopy with bougie
- Rescue: Supraglottic airway as bridge to surgical airway

🔹 Clinical Pearl: Document airway management challenges and techniques used for future reference. These patients may require multiple procedures during recovery.

ICU Protocols for Hormone Management

Decision Framework for Hormone Continuation

The decision to continue, modify, or discontinue gender-affirming hormones during critical illness requires individualized assessment:

Factors Favoring Continuation:

Stable patient without contraindications
Short expected ICU stay (<7 days)
No active thrombotic complications
Patient's expressed wishes when competent
Significant psychological distress with discontinuation

Factors Favoring Discontinuation:

Active VTE or high bleeding risk
Hemodynamic instability
Liver dysfunction (affects hormone metabolism)
Prolonged critical illness (>14 days)
Drug interactions with critical care medications

Evidence-Based Protocol for Hormone Management

Assessment Phase (First 24 Hours):

Complete hormone history
- Type, dose, route, duration
- Last administration
- Patient's concerns about interruption
Risk stratification
- VTE risk assessment
- Bleeding risk evaluation
- Drug interaction screening
Consultation
- Endocrinology if available
- Patient's hormone prescriber when possible

Management Protocols:

For Estrogen Therapy:

Low-Risk Patients:

Continue current regimen if no contraindications
Switch to transdermal route if on oral therapy
Daily VTE risk reassessment

High-Risk Patients:

Discontinue immediately if active VTE
Consider dose reduction for intermediate risk
Resume when clinically stable (typically >48 hours post-acute event)

For Testosterone Therapy:

Stable Patients:

Continue current regimen
Monitor hematocrit every 48 hours
Adjust dose if hematocrit >54%

Unstable Patients:

Consider holding if severe illness
Resume when metabolically stable

🔹 Clinical Hack: Develop ICU-specific order sets for transgender patients including hormone continuation protocols, VTE prophylaxis guidelines, and consultation triggers.

Monitoring Parameters:

Daily Assessments:

VTE signs and symptoms
Bleeding complications
Fluid balance (estrogen can affect sodium retention)
Mood and psychological status

Laboratory Monitoring:

Complete blood count (hematocrit for testosterone users)
Coagulation studies if anticoagulated
Liver function tests
Hormone levels (if clinically indicated)

Specific Clinical Syndromes

Transgender-Related Complications Requiring ICU Care

Hormone-Induced Complications:

Estrogen-Related:

Severe VTE (PE, DVT, cerebral sinus thrombosis)
Hypertensive crisis (rare, with cyproterone acetate)
Severe mood changes with abrupt discontinuation

Testosterone-Related:

Polycythemia with hyperviscosity syndrome
Sleep apnea exacerbation
Severe acne with secondary infections

Surgical Complications:

Immediate Post-Operative (0-72 hours):

Hemorrhage
Airway compromise
Anesthetic complications
Pain crisis

Early Complications (3-14 days):

Infection
Wound dehiscence
Thrombotic events
Urinary complications

Late Complications (>14 days):

Chronic pain syndromes
Reconstructive failure
Psychological complications

🔹 Oyster Alert: Non-medical grade silicone injection complications can present years later with granulomatous reactions, migration, or systemic toxicity. Maintain high index of suspicion in patients with unexplained inflammatory syndromes.

Psychosocial Considerations in Critical Care

Mental Health Comorbidities

Transgender patients have higher rates of:

Depression and anxiety (requiring ICU management in severe cases)
Suicidal ideation (particularly during hormone interruption)
Substance use disorders
Post-traumatic stress disorder (often healthcare-related)

Cultural Competency in the ICU

Best Practices:

Name and pronoun usage
- Use chosen name and pronouns consistently
- Update medical records appropriately
- Educate all staff members
Privacy and dignity
- Respect patient's privacy during examinations
- Consider room assignments carefully
- Involve patient in decisions about family notification
Communication strategies
- Ask about preferred family contacts
- Respect confidentiality regarding gender status
- Provide culturally competent discharge planning

🔹 Clinical Pearl: Simple gestures like using correct pronouns and chosen names can significantly improve patient cooperation and outcomes. This is particularly important when patients are conscious but unable to speak due to mechanical ventilation.

Medication Interactions and Considerations

Drug Interactions with Gender-Affirming Hormones

Estrogen Interactions:

Enhanced by: Protease inhibitors, azole antifungals
Reduced by: Phenytoin, carbamazepine, rifampin
Effects on other drugs: May increase levels of corticosteroids, benzodiazepines

Testosterone Interactions:

Warfarin: Enhanced anticoagulant effect
Insulin: May decrease glucose tolerance
Corticosteroids: Additive effects on mood and behavior

Anti-androgen Interactions (Spironolactone):

ACE inhibitors/ARBs: Additive hyperkalemia risk
Digoxin: Altered clearance
Lithium: Reduced clearance

Critical Care Medication Considerations

Sedation and Analgesia:

Standard protocols generally apply
Consider: Potential for underlying mood disorders
Monitor: For withdrawal syndromes if substance use history

Vasopressors and Inotropes:

No specific contraindications with hormone therapy
Monitor: Enhanced sensitivity in estrogen-treated patients
Consider: Fluid balance alterations with estrogen

🔹 Clinical Hack: Always verify hormone medications with multiple sources (patient, family, pharmacy records) as patients may use non-traditional sources or names for their medications.

Quality Improvement and Protocol Development

Developing Transgender-Inclusive ICU Protocols

Core Components:

Admission protocols
- Hormone history assessment
- Risk stratification tools
- Consultation triggers
Daily management protocols
- Hormone continuation decision trees
- Monitoring parameters
- Safety assessments
Discharge planning
- Hormone restart protocols
- Follow-up coordination
- Community resource connections

Staff Education Requirements:

Cultural competency training
Medical knowledge updates
Communication skills development
Legal and ethical considerations

Quality Metrics:

Length of stay compared to similar cisgender patients
Complication rates (particularly VTE)
Patient satisfaction scores
Readmission rates
Staff confidence surveys

Future Directions and Research Needs

Current Knowledge Gaps:

Optimal hormone management during prolonged critical illness
Long-term outcomes of hormone interruption during ICU stay
Specific drug interactions in critical care settings
Airway management outcomes post-facial surgery
Cost-effectiveness of transgender-specific protocols

Emerging Considerations:

Pediatric transgender patients requiring critical care
Novel hormone formulations and their ICU implications
Telemedicine consultation for transgender expertise
Artificial intelligence tools for risk prediction

Conclusion

Critical care management of transgender patients requires specialized knowledge of hormone-related complications, surgical considerations, and culturally competent care practices. The primary challenges include managing VTE risk in hormone-treated patients, navigating complex airway management after facial surgeries, and developing appropriate protocols for hormone continuation during critical illness.

Key recommendations include:

Early risk assessment for VTE in all hormone-treated patients
Specialized airway management protocols for post-facial surgery patients
Individualized hormone management based on clinical stability and patient factors
Culturally competent care practices throughout the ICU stay
Multidisciplinary approach involving endocrinology, surgery, and mental health specialists

As the transgender population continues to grow and seek gender-affirming care, critical care physicians must develop expertise in these unique considerations to provide optimal patient outcomes. Further research is needed to establish evidence-based protocols and improve our understanding of transgender-specific critical care needs.

References

Reisner SL, Poteat T, Keatley J, et al. Global health burden and needs of transgender populations: a review. Lancet. 2016;388(10042):412-436.
Flores AR, Herman JL, Gates GJ, Brown TNT. How Many Adults Identify as Transgender in the United States? Los Angeles, CA: The Williams Institute; 2016.
Bauer GR, Scheim AI, Pyne J, Travers R, Hammond R. Intervenable factors associated with suicide risk in transgender persons: a respondent driven sampling study in Ontario, Canada. BMC Public Health. 2015;15:525.
Getahun D, Nash R, Flanders WD, et al. Cross-sex hormones and acute cardiovascular events in transgender persons: a cohort study. Ann Intern Med. 2018;169(4):205-213.
Mohammed K, Abu Dabrh AM, Benkhadra K, et al. Oral vs transdermal estrogen therapy and vascular events: a systematic review and meta-analysis. J Clin Endocrinol Metab. 2015;100(11):4012-4020.
Hembree WC, Cohen-Kettenis PT, Gooren L, et al. Endocrine treatment of gender-dysphoric/gender-incongruent persons: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2017;102(11):3869-3903.
Bizic MR, Jeftovic M, Pusica S, et al. Gender dysphoria: bioethical aspects of medical treatment. Biomed Res Int. 2018;2018:9652305.
Sterling J, Garcia MM. Fertility preservation options for transgender individuals. Transl Androl Urol. 2020;9(Suppl 2):S215-S226.
Coleman E, Radix AE, Bouman WP, et al. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. Int J Transgend Health. 2022;23(Suppl 1):S1-S259.
Deutsch MB, ed. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People. 2nd ed. San Francisco: University of California San Francisco; 2016.

Friday, July 25, 2025