Good afternoon. Can everyone hear me? My name is Valerie Diaz, and I'm a member of the Professional Development Committee for AANA. Before we begin this session, I have a few reminders, some housekeeping points. For everyone here in the room, make sure that you've already downloaded our AANA meeting app, and I'm sure that you have. In order to receive your continuing education credits, you must complete the evaluation. The evaluation will be available to you 15 minutes before the close of this session. Attendees have until Monday, September 9, 2024, at 12 noon Pacific Standard Time, to claim continuing education credits. You can send questions to speakers via the questions icon located within this session. I will monitor the questions throughout this presentation. If time permits, your questions will be answered live by our speakers. In-person attendees may come up to the microphones conveniently located on the aisle to ask your questions. Lastly, please mark your calendars. We are looking for speakers such as yourselves for our 2025 Annual Congress in Nashville, Tennessee. I'm already excited. If you'd like to speak and share your expertise, the Call for Abstracts will open on August 14, so have your eyes peeled to your email. For more information about the submission guidelines, please visit aana.com. Now it is my distinct pleasure to introduce speakers Dr. Nelson Aquino and Harper Berriman. Dr. Aquino is a senior CRNA in Boston Children's Hospital's Department of Anesthesiology, Critical Care and Pain Medicine for the past 15 years. Harper Berriman is a Senior Behavioral Health Counselor at Boston Children's Hospital and is a transgender male who received gender confirmation surgeries without further ado, I welcome the speakers to the stage. Please enjoy. Good afternoon, everyone, it's a pleasure to be here and good afternoon to everybody online. I'm here to share my presentation entitled Exploring the Challenges and Anesthesia Outcomes of Transgender and Gender Diverse Individuals in the Perioperative Setting, an Unaddressed Research Gap. Before I begin, I'll share some fun facts about myself. One is truly an honor to be here representing Goldie Bragdon. When I was a student back in 2009, I had an opportunity to meet Goldie and Dr. John Gard, both champions for diversity, equity, and inclusion. In my free time, I'm an actor, background actor. My latest film was in Free Guy with Ryan Reynolds and Jodi Comer. I am a true Swifty. I've been to four E-Rest tours, as I call it, the Boston Rain Show, LA Film Show, Paris, where the Torture Poets Department was premiered night one and two, and hopefully will be going to Vancouver for the final E-Rest tour as it closes. And lastly, I am proud to be standing here in front of all of you as a Filipino-American nurse anesthetist as we launch the Filipino-American Nurse Anesthesiology Society. Thank you. Thank you to the AANA for celebrating this milestone, my board members and fellow founding members for coming here and supporting us. And please check out our website at FANAS.org. I have no conflicts of interest, but I do have some additional disclosures. I am not a gender-affirming surgeon, endocrinologist, or psychiatrist, but I am a doctoral-prepared CRNA that studies the perioperative outcomes for this vulnerable population. Completing a World Professional Association of Transgender Health Certification, gender-affirming medical and surgical care is complex and controversial, and this presentation will fail to cover the full depths of these complexities. For consistency, I will use the term transgender to include transgender, non-binary, and gender-diverse. So our learner outcomes, we're going to summarize the current climate for transgender individuals in the perioperative setting, we'll describe gender-affirming care, current clinical anesthesia considerations, and its application in anesthesiology. I'll analyze anesthesia and perioperative outcomes for gender-diverse surgeries, and As we delve into the end of this presentation, we will embark on the transformative journey of Harper Berryman, who is a resilient transgender man, advocate, patient, and friend. And through Harper's compelling life story, we are invited to witness the world through a different lens, sparking new perspectives and understanding. If you are free Monday, August 5th, I encourage you all to attend Anne Havrilla's lecture. Her presentation will offer an introduction to transgender terminology, aiming to prevent misgendering. Student nurse anesthetists and nurse anesthesiologists unfamiliar with this community may benefit from hormone therapy education and special perioperative considerations. And as I introduce this presentation, I think it's important to go over some basic terminology. The Diagnostic and Statistical Mental Disorders refers to gender dysphoria as distress caused by a mismatch between one's gender identity and sex assigned at birth, impacting daily life. However, in 2025, the International Classification of Diseases updates this terminology to gender dysphoria, to gender incongruence, thus removing this term as a mental condition, improving access to care and improved outcomes. Not all transgender individuals experience gender dysphoria. You are cisgender if you identify with the gender assigned to you at birth. Transgender is an umbrella term that encompasses individuals whose gender identity differs from those assigned at birth. Nonbinary describes individuals who identify or express their gender beyond the binary male or female. And gender nonconformity relates to how a person's gender identity or expression diverges from what society expects from us. So what are the current statistics? Well, the Williams Institute report suggests that approximately 1.5 million adults identify as being transgender. And sorry, I'm too far. And other population-based studies in 2022 show that an increase in transgender youth from 1.4% to 2.7%, which equals about just under 700,000 youth ages 13 to 24. The 2015 U.S. Transgender Adult Survey of 28,000 adult respondents sheds light on patient interactions with health care providers. 33% of those individuals, adults, had native experiences with health care clinicians. 23% did not want to see a doctor. And 40% of those attempted suicide in their lifetime. And factors like nonacceptance, minority stress, and the stigma contribute to those elevated suicide rates. The 2022 U.S. Transgender Survey is the largest ever study of the experiences of binary and transgender individuals ages 16 or older. And the initial findings show that 48% of the nearly 92,000-plus respondents faced negative interactions with health care providers, whether it was verbal abuse, rough housing, or misgendering. And this alarming figure has not had any progress since the 2015 survey. However, the survey reveals that there is enhanced life satisfaction post-transitioning, whether it was medical transitioning, social transitioning, or surgical transitioning, despite societal changes. Legislative barriers target transgender individuals in the United States. Gender bills surged from 40 in 2018 to over 400 in 2023, mainly aiming to limit gender-affirming care. Some states enacted laws that prohibit or prosecute clinicians like myself, forcing patients to travel long distances and or lose access altogether. In light of these impactful statistics, let's explore the critical implications for lesbian, gay, bisexual, transgender, and queer youth and suicide. Among transmasculine youth, the suicide attempt rate stands at a staggering 50.8%, while transfeminine individuals face about 29%. And in stark contrast, the general population of adolescents is about 14%. These authors suggest transgender youth with supportive environments have the comparable concerns with their cisgender peers. I love to share this survey. In a 2019 CDC Youth Risk Prevention Survey, LGBTQ youth with one accepting adult were 40% less likely to report a recent suicide attempt. So as student nurse anesthetists and certified registered nurse anesthetists caring for transgender individuals, we can be allies, combat the stigma against transgender and nonbinary individuals. Many of you have heard about minority stress, and minority stress arises from living in a society that doesn't accept minority populations. For example, identifying as transgender leads to increased mental health issues like depression, anxiety, suicidal ideation, and harm. Many of our patients in the perioperative environment experience unintentional microaggressions such as misgendering. They come with different gender identity fields that causes us to say their dead name, for example. And then there are these macroaggressions or these larger scale anti-transgender laws that affect transgender individuals. For example, just getting a driver's license, going to a bathroom, or playing a sport. When we talk about intersectionality, sexual and gender, people of color, and lower socioeconomic statuses show higher rates of substance abuse, potentially impacting surgical outcomes. And so what can we do to alleviate minority stress? Well, we can promote dignity, mutual respect, and understanding. Discrimination for the transgender community is prevalent throughout the health care system. There is a lack of education. We don't learn about transgender care or the current considerations in our nursing programs, our medical programs. There is a lack of evidence-based literature and a holistic approach. And this translates into a workforce, including student nurse anesthetists and nurse anesthesiologists that are unfamiliar and unprepared to manage this unique population. And the consequences of these research gaps in care and training lead to lower trust between transgender patients and their providers. So what can we do to alleviate minority stress? Well, we can acquire the necessary knowledge, cultural humility, and skills to incorporate a bio-psycho-social approach and implement gender-affirming clinical care in our practice. Additionally, collecting information on transgender individuals to apply evidence-based practices in clinical anesthesia to improve perioperative outcomes and to improve the quality of care to improve perioperative outcomes and prioritize research for this marginalized population. And I'm truly confident together we can make a meaningful difference in the lives of transgender individuals under our care. Transgender people are an integral part of our society, appearing at every stages of life and in our daily interactions. They are our children, cherished ones, and the human beings we provide care for. For me personally, two of my nephews identify as being transgender. Both have had chest reconstruction surgery. Here's a picture of one of my nephews with my son. And as a parent, the only advice I can give is to lead by example. I work with a colleague who identifies as a transgender woman and as an anesthesiologist who is a professional in our organization and sits on editorial boards. And finally, for the patients that we care for. And you'll meet Harper today and learn about Harper and his journey. Having explored the profound experiences of transgender health care in the United States, I want to share my experience as CRNA that illuminates the controversy, division, and polarization that surrounds this highly politicized and debated topic. After sharing my 2020 research article to a CRNA forum, I received numerous contentious responses from my peers. Being affiliated with a children's hospital with gender programs across the lifespan often suggests that our gender-affirming surgeries are done on children. As you will learn in the slides, this is not the case. But I'll read some of the responses I got. This is disgusting. Anyone who participates in doing this to minors should go to jail. These surgeries are child abuse. What's the follow-up on these children years down the road when they realize and expect the permanence of these actions for something that may have been a temporary phase? I guarantee you many of these children live with regret and wish that some greedy plastic surgeon didn't take advantage of them and mutilate their body. In 2022, our institution faced many attacks on our gender-affirming programs. They attacked our gender-affirming endocrinologists, surgeons, anesthesia team. And regrettably, this was an increased focus on gender-affirming medical and surgical care procedures for adolescents. And social media has negatively impacted that for patients, families, and clinicians like myself. As I mentioned, I had a professional account, and one day I woke up, and they had tagged my research, creating their own narrative. And so despite these attacks, prominent health care organizations across the nation stand united in recognizing that gender-affirming care is life-saving and is crucial for the well-being and survival for transgender individuals. And I'm honored to announce that this year in 2024, the ANA Practice Committee, along with Dr. Daniel King, Dr. Jose Castillo, and numerous CRNAs have released practice guidelines for transgender patients. So having completed our first learner outcome, I will now review how we can implement this in our clinical practice. A comprehensive biopsychosocial approach is recommended when providing gender-affirming care for transgender individuals. Transgender individuals have a wide range of transition, whether it is a gender-affirming care program, a gender-affirming care program, or a gender-affirming care program. Transgender individuals have a wide range of transition, whether it is social, medical, or surgical, or no transition at all. And given our distinctive role in the perioperative care, student nurse anesthetists and CRNAs should understand the importance of supporting transgender patients across different health realms. Hormonal interventions involve pubital suppression and gender-affirming hormone therapy to assist transitioning, and they can be reversible or partially irreversible. And this can be an entire presentation in itself, but I want to focus on gender-affirming surgery and transgender anesthetic considerations. However, there are numerous studies that highlight the effectiveness of hormones as life-saving medical care in reducing gender dysphoria, alleviating anxiety, decreasing those suicidal thoughts and harms. In fact, puberty blockers such as histraline that reduces the gender dysphoria that young adolescents may have caused by secondary sexual characteristics before Tanner Stage 2 and 3 provides these individuals to catch up with their peers, facilitating mental health support and engagement with professionals and their families. A major component of the biopsychosocial approach is gender-affirming surgery, and gender-affirming surgery is increasingly common with improved surgical outcomes for young adults and adults. Here are some of the non-surgical options, which include facial hair removal, speech therapy for voice modification, genital tucking, and chest binding. Gender-affirming surgery often entails special surgical techniques that are evolving frequently. And CRNAs, SRNAs may find themselves providing care for transgender patients without prior exposure to these procedures of the specific needs of this population. There are numerous gender-affirming procedures that present with unique anesthetic considerations that necessitate a comprehensive understanding of the patient's needs. That necessitate a comprehensive understanding of the surgical process. In the secondary analysis of the 2015 Transgender Adult Survey, gender-affirming surgery is associated with improvements in decreasing psychological distress, reducing smoking and alcohol use, and suicidal ideation. This support needs to understand that surgical care for transgender and gender individuals is important. There's a lot of discussion around decision regret, and there have been multiple systematic reviews. But the most recent systematic review on decision regret consistently says that gender-affirming surgeries are low at 1%. When you compare this to other surgeries against the general population or cisgender individuals having breast reconstruction surgery, it's up to 47%. For those individuals having bariatric surgery, it's 19%. They even included other life decisions, such as having children, a 7% decision regret rate, for those having a tattoo and regretting it at 16%. So the instances of decision regret are rare and are typically related to surgical complications rather than the decision to undergo transitioning. Transgender individuals do not simply wake up one day and decide that they want to have gender-affirming surgery. It's a process. It's a journey that they go through. And before undergoing any procedure, a formal set of standards are set forth by the World Professional Association of Transgender Health, or the WPATH. And they must be followed. These standards are mandatory. They're based on international consensus guidelines by surgeons and their clinical nurses, doctors, other allied health care professionals. And they are recommended in various disciplines and by insurance agencies to safeguard the well-being of patients, families, and clinicians like ourselves. And for example, most of these procedures require mental health evaluations, medical evaluations. Some require patients to live in an association for more than a year beyond hormone therapy. And they have to have a discussion about fertility, especially for those procedures that are irreversible. Not all gender-diverse or transgender individuals may seek interventions. Gender-affirming age requirements align with each country's age-specific consensus guidelines. So in the United States, chest reconstruction and genital surgery are not a requirement. Chest reconstruction and genital surgeries are typically available for individuals ages 18 or older, although there may be exceptions for those older adolescents meeting WPATH criteria with parental consent for chest reconstruction surgery. And the latest WPATH Standards of Care 8 recommend the comprehensive multidisciplinary approach for transgender individuals, which emphasizes open communication and care coordination and improved perioperative outcomes. And so at our institution, we have a gender multi-specialty service that started out with ambiguous genitalia and then ended up evolving for transgender individuals that helps with mental health issues, medical management. In 2017, our institution created the Center of Gender Surgery, which offered gender-affirming procedures for those 18 or over. And so in 2019, in our perioperative environment, we started seeing an increase of patients having chest reconstruction surgery, there was a phalloplasty, and we didn't have any education or understanding of this. And I'm really proud to share that for CRNAs, we started out as a grassroots team. We created this team. Our goal was to establish a program. We called it the Gender-Affirming Surgical Perioperative Program, or the GAS program. And our goal was to effectively address the preoperative, anxiety, and coexisting morbidities, preoperative, the unique considerations and postoperative needs, like pain management and outcomes for transgender individuals in our environment, whether it was for a gender-affirming procedure or a non-gender-affirming procedure. We aim to offer inclusivity and cultural sensitivity for our patients and families with a consistent team of providers. We actually convinced our leadership, and we actually got an administrator. We have a research coordinator. We have a research nurse. We even have patients that are part of our team that represent in our program, and Harper's here today to do that. And our key areas focus on creating clinical guidelines. You know, we were able to capture all the gender-affirming cases that came into our environment and get the experiential knowledge that we needed. We were able to use ICD codes to participate in all these procedures, especially the gender-affirming procedures. We do transgender education for our hospital, for our nursing colleagues, for our medical colleagues, and then we collect outcomes and evaluation. And so collaborating with a dedicated and gender-focused multidisciplinary team brings numerous benefits and improves surgical outcomes, as I will share in our original research studies. And so our first study, a single-center case series of gender-affirming surgeries and the evolution of a specialty anesthesia team, we looked at chest reconstruction surgeries and genital surgeries, and what we identified, 204 surgeries from 2017 to 2020. The median age of our patients was 18 years old. Most of these patients were ASA 1 and 2, and most of our patients identified as transmasculine for most of the procedures that we offered for masculinizing procedures. There were a total of 107 chest reconstruction surgeries and 27 genital surgeries. We looked specifically at opioid malequivalence, pain outcomes, adverse events, and so forth. And we continually gather and analyze data and demographics as part of our ongoing efforts. In addition, we closely monitor pain scores, regional anesthesia usage, bleeding rates, anesthesia management, and adverse outcomes on a continuous basis. And so for our 2020 to 2022 genital surgery cohort, we had an additional 33 genital surgeries, including phalloplasty, metoidoplasty, and vaginoplasty. Our median age was 23. Most of our patients were split now between transfeminine and transmasculine, and we started seeing regional anesthesia. And this data is utilized in collaboration with our surgeons, nurses, and other allied health providers to create and develop enhanced recovery after surgery protocols. And so I'll go through some of the common gender-affirming surgeries. Most of you are familiar with masculinizing chest reconstruction or mammoplasty, informally known as top surgery. And these are for individuals that are born female that identify as more masculine or non-binary. And the operative goals include excision of breast tissue and excess skin. Some patients do want their nipples placed back on, others do not, achieving a well-contoured chest with minimizing scars. And I don't expect everyone in the back to read this, but I just wanted to share that we have created enhanced recovery after surgery protocols based on our previous outcomes, the existing evidence in breast reconstruction ERAS literature, the evidence related to our anesthesia principles, and being able to capture all these cases over a two-year time period. And our gender-affirming pathway includes delivering gender-affirming care, managing postoperative nausea and vomiting, reducing opioid usage, and preventing any type of hematomas. In fact, it was our nurse anesthetist, after we started seeing an increased amount of patients coming back to the operating room for hematoma evacuation, they challenged the status quo. For many of us, we have used trans-isamic acid and anti-fibrolinic in our practice, so we suggested it to our plastic surgeons, and we instituted this in our protocol. And so are there any student nurse anesthetists out there? There you are. Any DNP students? Excellent. Well, this was my capstone project, which ended up being an entire research study, and it's called the Implementation of an Enhanced Recovery After Surgery Pathway for Transgender Individuals Undergoing Chest Reconstruction Surgery. And so I looked – this is an observational retrospective study. I looked at three different groups of patients, a traditional group that just received anesthesia from anesthesiologists, nurse anesthetists, trainees. And then when our team got involved, and we created a clinical guideline, and then when we formalized the ERAS group. And I identified 362 patients in three epochs over time, and we revealed that the ERAS protocol significantly reduced length of stay compared to the traditional approaches. And specifically, trans-isamic acid was linked to a shorter length of stay when we did a multivariable regression analysis based on medications, based on ASA status, regional anesthesia, and so forth. We also decreased the return – the JP drainage and PACU drainage of JP drains, but we had a meaningful outcome. We reduced the return to the operating room for hematoma evacuations in 24 hours. And this was really important. Our findings suggest that a comprehensive ERAS pathway tailored for gender-affirming surgeries can lead to improved patient outcomes, including reducing complications and a faster recovery. The next surgery I'll go through is genital surgery. Phalloplasty is often a staged procedure. This is for those born female that identify as more male. It's also known informally as bottom surgery. It's usually a combined plastics and urological procedure. And the phalloplasty is an option for those trans-masculine individuals seeking a phallus anatomy, standing upon urination, and penetrative sexual intercourse. This procedure includes many stages, including the vaginectomy, urethral lengthening, suprapubic placement. At our institution, we use the radial forearm free flap to create the phallus. And then they come back four weeks later for a skin graft and then for the glands. And unfortunately, many patients do have multiple complications related to urethral strictures and come back for other procedures. And again, I don't expect you all to read this in the back, but I just wanted to show that we do have clinical guidelines that we have created based on our experiential knowledge. There is a gap in academic literature regarding anesthesia management of phalloplasty surgery. And so our anesthesiologists, nurse anesthetists, trainees, anybody can look at these guidelines and use them as guidelines. And I'll summarize some of the anesthesia and surgical considerations, some of the lessons we learned. We found that multidisciplinary communication is essential. These procedures are long. They can last up to 16 hours. The length of surgery is long, and we've had patients with paresthesia. So we collaborated with our nursing teams, and we moved the legs and the extremities every hour. We do this with general endotracheal tube anesthesia, positioning, as I mentioned, is important fluid management, and then a multimodal pain regimen. We instituted DVT prophylaxis. We are considerate of the tourniquet time. Our patients all went to the intensive care unit for the anastomosis monitoring of the phallus. And as I mentioned, many have had long-term complications related to this procedure. Another genital surgery are those that are born male that identify as being female, which is the vaginoplasty surgery. And at our institution, gynecologists and urologists perform these procedures. And the vaginoplasty procedure involves creating a clitoris, a labia, and vaginal canal suitable for sexual intercourse. The most common technique is penile inversion. And this is where the penile and scrotal skin is used to make a vaginal canal. And so for some patients, they don't wish to have that. They can have a zero-depth vaginoplasty, known as a vulvoplasty, or they can come back later and have the canal created. And today, I'm going to share with all of you unpublished data from our pilot study aimed at improving outcomes such as hospitalization rates, nausea, vomiting, and pain management. In this retrospective observational cohort study, we implemented preemptive epidural anesthesia in nearly every patient. And thus far, we have not observed any significant impact on the pain scores or return to functional status such as getting out of bed or first stool. But we continue to gather data highlighting the importance of conducting larger multi-center trials. The average age of our patients in our study was 21 years old and with a normal BMI. Interestingly, we noted a 56% rate of PONV among transgender women having vaginoplasty surgery. And when we compared this data with another academic urban institution, which involves nearly 150 patients and remains unpublished, we have discovered similar outcomes regarding nausea and vomiting as well as pain management. Therefore, we hypothesize the increased incidence could be related to the orchiectomy or the removal of the testicles in the vaginoplasty procedure. And lastly, I'll talk about facial feminization surgeries and the surgical interventions that may encounter in your practice providing care. And I'll review some of the anesthesia and surgical considerations. Facial gender surgery can be both facial feminization or facial masculinization surgery. Facial feminization is more common because some of the testosterone effects cause more facial masculinization procedures. And this is typically an elective outpatient procedure. We have to be cognizant when placing an endotracheal tube because some of these patients may have had previous vocal cord surgery. And I'll go through that in the next slides. And so the recommendation is to avoid reintubation for three months. We do tracheal shaving or thyroid chondroplasty at our institution. We use the case report from Boston Medical Center. And we use an LMA for the ENT surgeons to do fiber optic guidance. And I don't know if you can see in the slide, but there is a needle going through the cricothyroid to identify the anatomy. And this is a very high-risk fire procedure, so effective communication. We do a total intravenous anesthetic and POMV prophylaxis, and our patients go home the next day. And so changing focus, I acknowledge that not all of you in the work settings are going to provide care for gender-affirming procedures, surgeries. And therefore, I will now review the essential perioperative considerations of every transgender patient. And this figure offers an overview of the prevalent medical, surgical, and psychiatric considerations for transgender individuals. While I cannot go through all of these in each aspect today, I will highlight six key considerations that you should be mindful of in the upcoming slides. And for those of you who are familiar with the two previous editions of the care of the transgender patient perioperatively, Louis Tolinch has been the leader or pioneer in writing these articles, review articles in gender-affirming care and anesthesiology. And I'm pleased to say that Dr. Tolinch and our collaborators have recently updated this review article and is currently in press and scheduled for publication in 2025. And so the six perioperative considerations that I believe are essential to review include airway, chest binding, drug interactions, postoperative nausea, vomiting, pregnancy testing, and venous thromboembolism. So we'll begin with airway. So transgender patients may come to the perioperative environment that pose airway management issues, particularly transgender women that have had previous vocal cord procedures or tracheal shaving. And you can see in the center picture, that is 12 weeks post-glottoplasty where the vocal cords are abducted, and 14 weeks later where the vocal cords are abducted. So it's important to use a smaller size ET tube and consider. And based on the literature and interviews and surveys with ENT surgeons, avoiding intubation 12 weeks post-glottoplasty. In unpublished research of anesthesia colleagues that looked at the incidence of unanticipated airway events in male to female transgender patients undergoing facial feminization surgeries, this retrospective study of nearly 300 facial feminization patients who underwent plastic procedures, they showed no airway events when they compared it to those cisgender patients having similar rhinoplasty procedures. Chest binding. So chest binding is a practice of compressing or reducing chest tissue that often causes gender dysphoria for transmasculine or non-binary individuals. And this process can utilize a lot of tape. It can be painful. There have been reports of skin irritation, fungal infections. There is a lack of data related to this. And in a cross-sectional study in 2018, 89% of these individuals report at least one negative symptom. And I want to share with you two case reports. One is from an anesthesiologist reporting on a 19-year-old transgender patient coming in for an EGD and natural airway. And the patient had a desaturation event requiring intervention. And they found afterwards the patient had a chest binding on that wasn't removed. And so it's important to interview your patients and see if they have this prior to having any anesthetic. In another case report that I report, we report a transgender adolescent coming for dental rehabilitation. And we had the discussion with the patient and the family. They removed the chest binding. But after the procedure in the recovery room, we forgot to place the chest binding back on. And the patient woke up and was in severe gender dysphoria and had an unplanned psychiatric inpatient admission. Drug interactions. There is some reports of estrogen that can reduce pseudocolon esterase activity. So it's important to check your neuromuscular monitoring. And we're all familiar with Sugamidex and its effect on oral contraceptives. But it's important to know that in the literature, in the insert, it says there's two estrogens. And so speaking to endocrinologists, it doesn't decrease the affinity. It's almost like missing a dose. So it's important to do post-op education versus gender-affirming hormone therapy versus using alternative ultracontraceptives, which is not the same. Post-operative nausea and vomiting. And some data that's come out from anesthesia research that doesn't really have any statistical significance, but shows that patients experience a higher incidence of PONV for those having facial feminization surgery versus those having rhinoplasty surgeries. And in this study, there was a 38% PONV rate in 100 cases. And interestingly, there was no other factors, including the presence or absence of hormonal therapy, that found to be predictors of PONV. Many of us are familiar with apretinib and exploring that as an alternative. It's a chemotherapy drug that works on the actions of neurokinin, which reduces nausea and vomiting. And apretinib has been found to reduce the affinity of oral contraceptives up to 43%. So it's important to educate transgender individuals that are capable of being pregnant to use alternative contraception for up to two months. Pregnancy testing. Pregnancy testing can often cause some gender dysphoria for patients. And I know this pathway may seem detailed and complex for assessing a pregnancy test, but it was developed out of necessity to educate our pre-op nurses. Because some transgender individuals were being asked to have a pregnancy test. So in summary, our guideline is simple. If you do not have a uterus or ovaries, we recommend a pregnancy test. And pregnancy may be possible in patients that were assigned female at birth that identify as transmasculine or non-binary and while on testosterone. And lastly, venous thromboembolism. We're familiar with oral contraceptives and the risks associated with post-hormonal therapy and long procedures. And so although there is no definitive literature linking gender-affirming hormone therapy, there are risk factors such as cardiovascular risk, age, smoking, BMI, and our patient population. And in one study, they looked at 296 facial feminization procedures, and they found that there was no incidence of VTE. And they followed up patients one year and one week after these procedures. And so with the completion of our second and third learning outcomes, I'll conclude by discussing some trends and research initiatives. National studies, database studies, looking at insurance and ambulatory databases provide the demographic landscape, but they don't, and surgical access, but they don't look at the intricacies of anesthesia outcomes that we all are interested in. There is an increase in 389% of chest reconstruction procedures over a three-year period. And I'm happy to share at our institution, since the institution or our team, we've taken care of nearly 2,000 patients that identify as transgender. 40% of them had undergone non-gender-affirming procedures. And lastly, as I deliver this, like, 30-plus presentation on the evolution of transgender surgical anesthesia outcomes, there is literature that remains sparse. These are the handful of studies that have been done. That are anesthesia outcomes studies by the anesthesiology workforce. The literature remains sparse on quantifying perioperative risks, evaluating short- and long-term perioperative outcomes. And most of these studies have been single-center studies, which are more detailed and plagued by limitations such as single surgeon and small sample sizes. And it compromises generalizability. And this brings us to the creation of one big partay. And partay is the mnemonic for the perioperative anesthesiology registry for transgender adults and youth, which I established last year. And this multi-center collaboration aims to gather data and exchange clinical experiences to enhance and ensure safe care and outcomes for this population. The inclusion criteria is anybody seven years or older that identifies as being gender diverse for any non-gender-affirming or gender-affirming procedures. Some of the questions that we want to explore is chest binding practices, anesthesia management for different gender-affirming surgeries across different centers. Perhaps we can understand the role of gender-affirming hormone therapy, POMV. Is there a difference between transgender individuals that we care for against the general population? And lastly, we can create consensus guidelines based on evidence. And with the support from a grant from my institution, I've had the privilege to establish and fund this group. I take great pride in organizing a two-day symposium face-to-face that laid the foundation to this unique transgender registry. And as I conclude my presentation, partay is grateful to have garnered interest from 14 institutions in our multi-center collaboration. If you or your institution is interested, please reach out to me. And I appreciate all of you for taking the time to engage in my work and journey as a doctoral CRNA dedicated to advancing evidence-based neurosanesthesiology practice. And so now I would like to introduce my colleague, my friend, and patient, Harper Berryman. Thank you, Nelson, and the AANA for the opportunity to share my story. My name is Harper Berryman, and I'm a senior behavioral health therapist on the inpatient psychiatry unit at Boston Children's Hospital, a graduate student working towards my master's degree in clinical mental health counseling, and as you all now know, I'm a transgender man who has had life-changing gender-confirming procedures done at Boston Children's Hospital. And so I'm here to share my story. I'm a senior behavioral health therapist on the inpatient psychiatry unit at Boston Children's Hospital, a graduate student working towards my master's degree in clinical mental health counseling, and as you all now know, I'm a transgender man at Boston Children's Hospital. To properly explain just how important my experiences with the gender-affirming surgical perioperative program has been, I'd like to first share a bit of my background. I've known I was transgender since the moment I was born. I know that sounds cliche, but it's true. I cried and ripped off dresses when I was a toddler. I was only wearing a diaper in a good portion of the photos of me as a young child. I insisted on wearing my brother's old clothes and always played the dad or older brother and family-type games with friends. When I was three, I did what any child would do when something was wrong, and I told my mom. The word transgender was nowhere near my vocabulary, but I told her this. Mom, something's wrong. We need to go to the doctor. They gave me the wrong body. I'm a boy. Now, my mom's a problem solver. She saw a distressed child and had little to no background knowledge on anything to do with this or transgender or honestly anything of the sort, and she replied with the following. No, honey. You're fine. You just want to be like your older brother. Now, my brother's cool, but he's not medically change-your-body cool. In that moment, I began to think something was seriously wrong with me. I continued to wear his old clothes and play with the boys until kindergarten, but around this time is when kids tend to become more aware of gender and gender roles, and this is when the bullying started. The boys I was friends with slowly distanced themselves from me, and the girls seemed to truly enjoy throwing glitter at me and calling me the freaky tomboy. The bullying lasted through middle school until I eventually decided to play the part. I went all in. I wore the skinny jeans, the push-up bras, the makeup. I even had a boyfriend. I wanted to fit in, end the bullying, and stop making others uncomfortable. Yes, I felt and still often feel like it's my responsibility to make others comfortable with the idea of my very existence, but all this occurred at the cost of my mental health. I became those statistics Nelson mentioned earlier. I hated myself and everything about my body and my life. I was miserable. I slowly began to check out of life until I completely dissociated from existence. How can you connect to the world around you when you can't even connect to yourself? I hit what most would call rock bottom in my senior year of high school and could no longer keep it together. I couldn't fake it anymore. One day I realized I had spent my life being miserable just to make sure others were happy when they weren't really doing the same for me. I had to make a choice. Do I fight for myself or do I continue to fight against myself? I chose to fight for myself, and that decision both changed and saved my life. A lot of people have the misconception that once you come out as transgender, things get immediately easier. That's not true. Once you share this portion of yourself with the world, you can't just take it back. I wasn't a three-year-old anymore. I was 18 and I was in control of my life, or at least in theory. And I just had to put my head down and fight, especially during that, let's call it, awkward stages of second puberty. The public ridicule, the judging looks from strangers on the subway, verbal harassment by drunk strangers, the need to prove to doctors and insurance companies that I was who I said I was, the family therapist telling my parents and siblings not to use male pronouns because it was just feeding into the attention-seeking behavior, and they needed to show me that they weren't supposed to be playing into my games. All the while, I kept my head down and told myself that I needed to do what I needed to do in order to get to who I needed to be. The message of, while you're the weird one here, they get to question you and say those things was overwhelming in my life. And honestly, still something I hear myself thinking when people ask me things such as, so what do you have? Prior to my transition, I was very fortunate to have been in good physical health and not have required any surgical procedures. Since beginning my transition in December of 2015, to date, I've had 20 surgeries. The first four of those procedures were not done with the team at Boston Children's, and with each of those procedures, the days leading up to them were not filled with excitement for the next step in my journey to becoming me. They were filled with fear and anxiety, not over whether something would go wrong or I wouldn't wake up, or about the pain I would be in following surgery. I was scared people would make fun of me when I was under anesthesia. Just laying there, naked, helpless, defensive, completely vulnerable. What did these strangers really think of me, of transgender people? Were they just doing these surgeries because of the backlash they would face if they chose not to? For the money? Or potentially worse, were they just indifferent, not even recognizing the life-altering procedure they were performing and the power to influence the rest of my life they had? Now, I assure you these concerns were not warranted. I don't think people realize how much time gender-diverse people have to spend convincing others, strangers, that we are who we say we are. Maybe it's because the idea of not aligning with your body is so hard to grasp for someone who has never felt such immense discomfort and self-loathing in their own skin. Maybe it's because people still believe this isn't a thing. Regardless, it's rare that people will just believe you. To afford these life-saving procedures and have them covered by insurance companies, I've had to provide numerous letters of support from various mental health care professionals, as well as primary care physicians, assuring that I was in the right mind and had been actively living as my chosen gender publicly for at least one year. So much of my ability to live as my authentic self has been completely relying on others' perceptions of my own gender presentation. Prior to passing, which refers to a person's ability to be perceived as their gender identity by others, I was referred to as it, freak, and various derogatory terms for lesbians by strangers in public. In many ways, I agreed. I felt like a freak with various mismatched parts. Wispy chin hairs and a high-pitched voice, hairy legs and double-D breasts that could not be camouflaged by a chest binder. I didn't speak up when I heard whispers of, oh, that's her, or him, I guess. Remember the catcher? Harper. Yeah, she's trying to be a guy now, I guess, on the rare occasions that I returned to my hometown. I avoided using public bathrooms at all costs due to fear of being verbally and or physically accosted in the bathroom. I was too small and feminine for the men's room and too butch for the women's room. I didn't fit in anywhere. Once I finally started to pass, I began to be othered in a whole different way. Prior to pursuing phalloplasty, I had the privilege of undergoing two cryopreservation cycles to freeze my eggs. This meant having to stop testosterone, thus slowing my physical progression towards manhood, and begin injecting myself daily with hormones to stimulate egg production. This process also involved going to the hospital each morning for blood work and transvaginal ultrasounds. Now, I know we just met one another, but I'd like you to do your best to picture a 21-year-old Harper sitting alone at 530 in the morning in the waiting area of the fertility clinic that I pursued care at, surrounded by cisgendered heterosexual couples. I kept my head down, wrote my name on the sign-in sheet, found a seat in the corner, and pretended to scroll on my phone to avoid acknowledging the quick glances in my direction and whispered questions of what I was doing there from nervous couples trying to distract themselves from their own anxieties. Now, picture a nurse entering the room and calling out, Harper, with a smile on her face, only to have that smile turn to a confused stare when I stood up and approached her. I began to walk out of the waiting area and towards the room where the labs were drawn, as I had done for the past week. I was stopped by the nurse. She told me this facility was only for women. Assuming she was under the impression that I was trying to donate sperm, as had been assumed the week prior, which was admittedly gender-confirming, I explained that I was transgender and freezing my eggs. She continued to stare at me, briefly glanced towards my pants, then shook her head and informed me again that this facility is only for women, and walked me back to the waiting area. Confused, embarrassed, and relatively defeated, I walked back to the front desk and started to write my name on the sign-in sheet again. The front desk clerk asked what happened, and once I explained, she quickly pulled aside another nurse and had her complete the necessary procedures right away. But the already feeble trust had been shattered. My embarrassment and shame threatened to engulf me as I laid on the table, legs spread, waiting for the ultrasound to begin. I contemplated stopping the process completely and never going back to avoid further shame, but I wanted a family one day, so I kept my head down and continued. The most upsetting part of that entire encounter was that I believed in my core that the nurse was right. I did not belong there. I did not feel welcome. Prior to that blatantly negative experience, I was merely treated. I was never welcomed. Following my egg retrieval, I underwent a complete hysterectomy. On the morning of my procedure, I recall numerous medical students surrounding my bed looking at me. Some asked questions, others just stared. I assumed they were all helping with the procedure until my surgeon walked in and sent all but one away. It was as though I was an animal at a zoo that kids were pushing to see, or more accurately, something to be added to an eager resident's CV A few days after the surgery, I began experiencing fairly significant bleeding, and the on-call doctor told me to come to the emergency labor and delivery room. Now, friends, I would like you to picture that same 21-year-old male approaching the front desk at the hospital around 2 a.m., stating that I was told by my doctor to come here. A sleepy-eyed male security guard looked at me for a full minute, minutes much longer than you think it is in the moment. I watched him struggle to comprehend what was occurring. That's labor and delivery. You know that, right? I stared back at him blankly and simply said, Yes, sir, I do. So he gave me my ID bracelet and told me where to go. By that point, I was too tired mentally and physically to care about being embarrassed, and I knew that this was the last step I needed to complete in order to start my phalloplasty journey with Boston Children's. For every low point and negative experience I had on this journey, there was a high point with the team at Boston Children's. From my initial consult appointment to this moment standing before you all right now, I felt supported, heard, valued, and safe with this team, so much so that I wanted to support others in accessing these procedures from this groundbreaking team and started a fundraiser to support uncovered medical costs for fellow trans individuals. From the moment I met Nelson and the GASP team, that fear of being judged while under anesthesia left my mind. I will never forget the first time I met Nelson. Wednesday, January 29, 2020. The day and night prior was filled with bowel prep, minimal sleep, and three trips outside with my new puppy. I had to arrive at the hospital at 530, and despite this being the biggest day of my life and my transition and the multiple pre-op appointments I had with the surgical team prior to surgery, where it was made perfectly clear that the team was caring and good people, I still found myself preoccupied with thoughts and fears about the people I had not yet met or vetted. The nurses and students in training, the anesthesia team, I had no idea. As I sat in the waiting room, I watched families with young children waiting to be called back to pre-op, and they stared at my mom and I as respectfully as they could, but they were clearly curious as to what this adult was having done. I waited patiently as the admitting nurses began coming into the room to call back patients and families one by one. One of the nurses brought the enthusiasm and an effort to ease the young family and children's fear as she walked into the room, made a big presentation of announcing, Mrs. and Mr., come on down, and there were multiple nurses that day, but I had a feeling she would be the one to bring me back. Something in my gut told me she was about to announce, Mrs. Harper, and that feeling was spot on. All eyes were on me as I solely stood up, waved to her, and said, I'm Harper. Her embarrassment with her mistake was only matched by my own. I knew her intentions were not malicious. In fact, since that moment, I've been admitted by her multiple times, and she has been incredible. She's even corrected others when making that same error in my chart and ensured that my gender marker was updated in my patient chart. However, that was admittedly not the best start to this big day. The next hour was full of anxious waiting, countless consent forms, medical jargon, my body being autographed by surgeons. It's an incredibly overwhelming experience. When I get overwhelmed, I tend to just kind of blank and don't take the time to actually acknowledge how stressed or panicked I am. Then I hear, knock, knock, outside of the curtain, and Nelson, the walking ray of sunshine, emerges from behind. After two minutes of talking to him, I knew I was in good hands. He immediately won over my mother, who's a nurse manager and holds medical professionals to a very high standard. His enthusiasm and passion for the work he does and the patients he cares for was clear. My mom still mentions the time he spent sitting with her while I was in surgery to give her an update and make sure she knew I was okay. Since that moment, I've never questioned whether people will make fun of me or even say the slightest potentially negative or judgmental thing because I know I have a team of people looking out for me. No matter what the surgery, surgery is an incredibly stressful, invasive, and potentially traumatic experience. For transgender people, we have the added political and social climate to consider when placing our well-being in the hands of medical professionals who are often strangers. Throughout this process, I've had four urologists, each with their own technique, ideas, and opinions on what was causing my complications. Some surgeons I didn't even meet until the day of my surgery. The consistency that Nelson and his team provided to me is truly priceless. To this day, the second I find out I need another procedure, I send Nelson a message to let him know. Almost always his reply is, what's the date? I'll be there. If he's booked or can't make it, he makes sure to tell me who's going to be there, and I don't even waste my time worrying about if I should trust them or not because Nelson trusts them. Going in for surgeries in the COVID era brought an additional level of chaos and stress. I was not allowed to have any support person with me, so I went in alone. But I was never actually alone. Nelson or another member of the GAS team was there to keep me company. I'll never forget sitting in pre-op, chatting with Beth, an anesthesiologist, and talking about what Netflix shows I'd been watching to pass the time while recovering. It isn't often that you're able to develop a relationship with your anesthesia team like that. She sat with me while the surgeons came in and went through consents and gave me some much-needed words of encouragement and support. While I was feeling frustrated about the seemingly never-ending process and very worried about a new surgeon, they know me, they get me, and above all, they genuinely care about me. I cannot say enough good things about the GAS program and the support they have given and continue to give me. There's so much hate in this world right now. It seems like every time I turn on the news or open my phone, there's either an update about a new anti-trans legislation being proposed, mass shootings, often both at the same time, video after video of ignorance and hatred demonizing transgender people and calling for the abomination of them, political figures openly referring to trans people as mutants from another planet, and demons and imps who come and parade before us and pretend that you're a part of this world. Discriminatory, ignorant people who hold the power to dictate my right to exist make people like Nelson so incredibly essential in this world. This is the message being thrown in the faces of transgender people everywhere at every moment of every day. Young children, just like the young Harper who cried himself to sleep, begging whatever power was out there to make me a lesbian so I wouldn't have to face the world and tell them something was wrong with me. But I was willing to settle for anything that I could get. Sorry. Begging to wake up as a lesbian so I wouldn't have to face the world and tell them I was something different than a female and cisgender person. That was the message I was given. Being transgender is wrong. Something is wrong with people if you are transgender. And that is the message so many transgender individuals are still given today. Sometimes it feels impossible and exhausting to simply exist as a trans person in this world. People like Nelson and the members of the GASP team make it better every day by making it possible that not only do I deserve to exist, but I deserve to exist and be cared for and valued in the medical setting. Quality care teams specialized in gender diverse needs matter because the kid on the right of this screen thought the closest they would ever get to facial hair was that burnt cork beard on Halloween. It matters because the teen on the right thought a tailored suit and a buzz cut would never be an option. It matters because the kid on the left thought a future with a person who genuinely loves them and cares for them as they are, not someone they are pretending to be, was an option. Simply put, this care matters because transgender people matter. Our safety matters, our happiness matters, and our wellness matters. Feeling safe, comfortable, and happy in your own skin should never be a privilege. People should not have to subject themselves to embarrassment and shame in medical settings in hopes of finally feeling whole in their body. Words will never fully explain the immense gratitude to Nelson and the team at Children's for what they have given me, a life I never gave myself permission to imagine as a child, a life I still have to pause and pinch myself over. But above all, they have given me the confidence to pursue moments like this where I can share my story in hopes of connecting with people like you who can then go on and change the lives of gender diverse people everywhere. It's important to mention that nobody is perfect. Slip-ups happen, and even the most genuine and well-intentioned people can do or say something without considering the actual meaning of it. Prior to one of my surgeries at Boston Children's, I was sitting in the waiting area waiting to be called into pre-op. As it was an early COVID-era surgery, there were a few people in the waiting area with me, and most of us were relatively far apart. The combination of social distancing and people's auditory processing systems not yet adjusting to communicate with masks on meant the room was fairly silent. A query between the receptionist broke the silence. We need a pre-op urine test, right? Are you sure? No, we do. She, he could still, right? For a moment, I felt as though someone reached into my stomach through my navel, grabbed my lungs and pulled. The air left my chest and I was frozen. The words pounded in my ears as I began to question the place I had dared to trust. The panic subsided as rapidly as it began. I reminded myself of the positive experience I've had with this team and knew it was moments like these where education was essential. I walked to the counter, leaned in and asked, are you wondering if I need to provide a pre-op urine sample? Their faces turned white as they both quickly glanced at each other and then back to me. Yes, we, um, we were just wondering if, they began to say. I spared them and said, I haven't had a uterus for a few years now, I can't get pregnant. They both sighed in relief and thanked me for clarifying and nervous giggled their way through an apology. I told them I was fine and returned to my seat. As I began to walk, I heard one say to the other, ugh, I wish I didn't have a uterus sometimes. This wasn't a malicious comment. It was an ill-informed comment. In the past, I would have closed in on myself and commenced negative self-talk while I counted down the minutes until I could leave. But I knew the team at Children's wanted to create a safe space. I knew I was welcomed and worthy of inclusive quality care. The moment I saw a member of the GASP team, I shared this experience with them and asked not for anyone to get in trouble, but for the team to advocate for more education and training for all professionals that gender diverse patients would encounter in this process. From a simple hello to the final words you say to someone as they're falling asleep on the table, the way you interact with your patients matters immensely. I don't say that to scare you or to make you second guess every interaction you have, but merely to remind you of the power you hold to impact a person's life and complete sense of self-worth. I'll close with something my parents said to me as a child when they feared my stubbornness was bound for world domination. Use your power for good. Thank you.

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