Lived experiences of transgender and nonbinary people in the perioperative context: a qualitative study
=======================================================================================================

* Hilary MacCormick
* Les T. Johnson
* Drew Burchell
* Allana Munro
* Gianni R. Lorello
* Ronald B. George
* M. Dylan Bould

## Abstract

**Background:** Transgender and nonbinary (TNB) people experience obstacles that create barriers to accessing health care, including stigmatization and health inequities. Our intention was to describe the lived experiences of TNB patients and identify potential gaps in the education of health care professionals.

**Methods:** We conducted a qualitative descriptive study influenced by phenomenology by interviewing with TNB adults who underwent surgery in Canada within the previous 5 years. We recruited participants using purposeful and snowball sampling via online social networking sites. Audio recordings were transcribed. Two authors coded the transcripts and derived the themes.

**Results:** We interviewed 21 participants, with a median interview duration of 49 minutes. Participants described positive and negative health care encounters that led to stress, confusion, and feelings of vulnerability. Major themes included having to justify their need for health care in the face of structural discrimination; fear and previous traumatic experiences; community as a source of support and information; and the impact of interactions with health care professionals.

**Interpretation:** Participants detailed barriers to accessing care, struggled to participate in shared decision-making, and desired trauma-informed care principles; they described strength in community and positive interactions with health care professionals, although barriers to accessing gender-affirming care often overshadowed other aspects of the perioperative experience. Additional research, increased education for health care professionals, and policy changes are necessary to improve access to competent care for TNB people.

[See related editorial at www.cmaj.ca/lookup/doi/10.1503/cmaj.240878](http://www.cmaj.ca/lookup/volpage/196/E828)

Transgender and nonbinary (TNB) identities can be defined as when “gender identities and/or gender expressions are not what is typically expected for the sex to which they were assigned at birth” or are outside the binary of woman and man, respectively.1 People who identify as TNB are more likely to delay or avoid seeking medical care because of fears and experiences of discrimination or mistreatment and lack of transgender-competent health care professionals.2–5 They may also experience social, political, financial, and legal obstacles in accessing health care, further contributing to health inequities.6 These obstacles are not exclusive to TNB adults. A systematic review of TNB youth detailed numerous barriers to accessing gender-affirming care — an umbrella term referring to all aspects of transgender-related health care, including both surgical and nonsurgical care — including long wait-lists, lack of qualified health care professionals, financial costs, discrimination, and lack of family support.7

A substantial knowledge gap persists among perioperative care professionals who care for transgender patients.8–10 Throughout the United States and Canada, an increasing number of legislative and policy changes have further limited access to gender-affirming care.11,12 Access to gender-affirming care is associated with improved mental health outcomes, including decreased suicidality.13–16 To provide a safer health care environment for this at-risk population, the medical community must amplify transgender voices in efforts for inclusive perioperative care.

A growing body of literature addresses transgender-specific health needs, particularly in the context of primary care.1,4,5,17–20 Although not all TNB people choose to transition medically with hormone therapy or gender-affirming surgery, all people have the potential to require non-gender-affirming surgery at some point. Makhoul and colleagues’10 qualitative study characterized the experiences of transgender adults seeking gender-affirming surgery in the US, and Samuels and colleagues21 described the experiences of transgender and gender-nonconforming patients in the emergency department setting. Both studies highlighted challenges and barriers in accessing health care and a need for increased education for health care professionals. However, Canadian studies that explore overall perioperative care, in addition to gender-affirming surgery, are needed. Many TNB communities have been underrepresented in the literature.22 We sought to explore the lived experience of TNB patients in the perioperative context.

## Methods

### Study design

We conducted a qualitative descriptive study influenced by phenomenology to understand the lived experiences of TNB people in perioperative settings.23–25 Using this approach, we relied on hearing from patients as they recalled their journeys through the perioperative period, and used these rich descriptions to explore and interpret their experiences. Phenomenology seeks to describe the overall essence of the experience and participants’ interpretation of the events.26 Our methodology allowed for detailed exploration of the perioperative experience, grounded in the worldview, vocabulary, and context-specific experiences of the participants themselves.

We purposefully assembled a research team comprising people with diverse lived experiences, including those self-identifying with a range of gender identities (cisgender, transgender, and nonbinary) and sexual orientations (queer and heterosexual), as well as those at various career stages (early, mid, and senior) and from various professions (anesthesiologists, researchers, and educators). Some authors hold postgraduate degrees and have expertise in qualitative research of this nature. Members of the team who collected and analyzed the data self-identify as queer, transgender, nonbinary, or a combination thereof. Throughout the research process, these authors remained reflexive in how their varied identities, experiences, power dynamics, societal oppression, and privilege may have influenced their interactions with participants, members of the research team, and all aspects of the research cycle.

We referred to the Canadian Professional Association for Transgender Health’s guidelines and the Consolidated Criteria for Reporting Qualitative Research checklist to help guide the development and reporting of this study (Appendix 1, available at [www.cmaj.ca/lookup/doi/10.1503/cmaj.240061/tab-related-content](http://www.cmaj.ca/lookup/doi/10.1503/cmaj.240061/tab-related-content)).30,31

### Participant recruitment

Using purposive sampling, we recruited participants using flyers that were distributed via online transgender networks and websites, social media (Facebook, Instagram, and Twitter), physician offices, and national support or resource groups. These flyers were forwarded and reposted for a snowballing effect to increase our reach throughout recruitment efforts. Our choice to employ purposive and snowball sampling was intended to focus recruitment efforts to a specific population that could provide meaningful and relevant data for our study. We included people who identified as transgender or nonbinary, were at least 18 years of age, and spoke English; they must have undergone any surgical procedure (performed in an operating room in the presence of anesthesia providers) in Canada in the previous 5 years. We chose a period of 5 years to allow participants to sufficiently recall their experiences. One of the authors (D.B.) screened for eligibility and interviewed all participants. Participants were not eligible if they did not identify as transgender or nonbinary at the time of the perioperative experience. For our study, we defined the perioperative period as beginning at the time a decision was made to undergo surgery until the time of discharge postoperatively. We provided participants with a $25 gift certificate after they completed their interviews.

### Data collection

We conducted 1-on-1, in-depth, semistructured interviews between October 2021 and June 2022. We audio-recorded interviews (Olympus Digital Voice Recorder, WS-852), conducted over Zoom, and had them subsequently anonymized and transcribed verbatim by an independent professional transcriptionist. We stored audio recordings in a secure drive according to our institutional policies. Participants completed 2 interviews to encourage reflection and increased depth during the second interview, as well as to minimize fatigue during a single interview session. Participants were in a private environment of their choice during the interviews. We developed a brief interview guide that included questions about participants’ identities and background, surgical experiences, from the decision to have surgery through to recovery, and thoughts and feelings throughout the perioperative process (Appendix 2, available at [www.cmaj.ca/lookup/doi/10.1503/cmaj.240061/tab-related-content](http://www.cmaj.ca/lookup/doi/10.1503/cmaj.240061/tab-related-content)). Before any participant interviews took place, we piloted the interview guide with members of the research team (D.B., L.T.J.). All interviews were conducted by D.B., who shared their role within the research team, their gender identity, and the team’s motivations for this study with participants. Participants did not have a pre-existing relationship with the interviewer. Participant recruitment and data collection continued until no new themes were being identified within the data set. We gave participants the opportunity to review their transcripts for accuracy and as a form of member checking.

Given the potentially sensitive nature of the topics discussed, we employed several measures to protect participants’ well-being. The electronic information and consent form included a list of mental health resources. We allowed participants to have a support person present during the interviews, although none chose to do so. The interviewer was instructed to stop the interview and offer support if participants appeared distressed. They encouraged participants to contact any member of the research team if they experienced any distress after the interview.

### Data analysis

We engaged in an iterative and inductive process of thematic analysis, as described by Braun and Clarke.27 First, 2 team members (H.M., L.T.J.) familiarized themselves with the data by listening to the audio or reading the transcribed interviews independently. They took handwritten notes of connections, notable phrases or statements, and trends. Next, they highlighted and described statements that addressed our research question. In the next phase of analysis, they coded these highlighted statements into short phrases or single words using NVivo qualitative data analysis software (version 14, QSR International), and grouped them into preliminary themes. Members of the research team (D.B., H.M., L.T.J.) met throughout the analysis phase to compare codes and finalize themes. Any differences in interpretation were resolved through discussion until agreement was achieved.

We followed Lincoln and Guba’s criteria for trustworthiness. 28 The analysis process included investigator triangulation of the data, whereby 2 investigators collaborated in coding, analyzing, and interpreting the data, with prolonged engagement (i.e., completing a literature review at the beginning of study development, having personal connections to or membership within TNB communities, repeating interviews, and immersing themselves in the data over a period of months) and persistent observation of the data (i.e., listening to the audio recordings, reading and rereading the transcripts, and analyzing, theorizing, and revising themes throughout).28,29 Verbatim participant language was used throughout. We then reanalyzed transcripts to ensure themes accurately reflected data and to code any data overlooked during the initial analysis.

### Ethics approval

We obtained institutional ethics approval from IWK Health.

## Results

We interviewed 21 participants. Participant characteristics are listed in Table 1. Eighteen participants completed 2 interviews. Two people completed a single interview before withdrawing, citing personal reasons, but consented to keep their initial interview in the data set. One person had 3 interviews because of technical difficulties that caused sufficient delay to require rescheduling. Interviews ranged from 18 to 91 minutes, with a median interview duration of 49 minutes.

View this table:
[Table 1:](http://www.cmaj.ca/content/196/24/E806/T1)

Table 1: 
Participant characteristics

A coding tree is presented in Appendix 3, available at [www.cmaj.ca/lookup/doi/10.1503/cmaj.240061/tab-related-content](http://www.cmaj.ca/lookup/doi/10.1503/cmaj.240061/tab-related-content). We compiled codes into 4 themes (Table 2) Although many participant interviews recounted positive health care experiences, an additional overarching theme was the stress, confusion, and vulnerability that participants felt in navigating a perioperative environment in which they did not seem to fit. Although all participants experienced barriers in their surgical journeys, many appreciated — or were surprised by — the levels of individual and community support in some perioperative spaces.

View this table:
[Table 2:](http://www.cmaj.ca/content/196/24/E806/T2)

Table 2: 
Selected quotes related to themes*

### Justifying the need for health care in the face of structural discrimination

Barriers to accessing gender-affirming care were described by all participants. Participants described numerous scenarios where they felt burdened to educate health care professionals about trans health needs (Table 2, quotes 1 and 2). Many participants described feeling as though they had to be their own case worker to navigate a complex system with little to no external guidance (Table 2, quotes 3 and 4). One participant remarked, “It wasn’t that the steps were overly difficult. Half the battle was figuring out what the steps were” (participant 18, woman/female and transgender, she/her).

Financial barriers further complicated access to gender-affirming surgery (Table 2, quotes 5 and 6). Some participants described paying out of pocket for private psychologists to meet criteria within specific timeframes. Electrolysis, which can cost thousands of dollars, was a strict requirement for some gender-affirming surgery procedures and was not always covered. Provincial health insurance failed to cover travel or accommodation costs for out-of-province surgeries. Further examples of structural discrimination included inaccurate options for gender markers within electronic medical records and gendered health care environments (e.g., describing obstetrics and gynecology services as “women’s health”) (Table 2, quotes 7 and 8). One of the hospitals specializing in gender-affirming surgery is in Quebec, so some English-speaking participants felt language presented an additional barrier (Table 2, quotes 9 and 10).

When faced with such challenges, participants described health care professionals as gatekeepers, which made them feel as though they had to fight for validation of their very existence (Table 2, quotes 11 and 12). One participant remarked about gender-affirming care, “It’s more than cosmetics; it’s our lives. It’s who we are” (participant 6, male, he/him).

### Fear and previous traumatic experiences

Most participants recounted an element of fear relating to interactions with the health care system. For some, this fear was the direct result of previous traumatic experiences both in health care and in other areas of life. For others, this fear related to knowledge of other TNB people who had experienced trauma or discrimination in health care settings. Fear affected various aspects of the perioperative period, with some participants describing feelings of heightened vulnerability and expressing a desire for a trauma-informed approach in the perioperative setting (Table 2, quotes 13–15). Some participants felt unable to participate fully in shared decision-making, particularly for gender-affirming surgery, for fear of being denied access to care (Table 2, quotes 16 and 17). Many experiences in the perioperative setting were described as impersonal or dehumanizing, with some participants feeling like “test subjects” (participant 5, queer/nonbinary, he/they) and others likening their experience in the operating room to feeling as though they were an object on a “conveyor belt” that was not designed for them (participant 13, trans/nonbinary person, they/them).

### Community as a source of support and information

When detailing the frustration of accessing gender-affirming care and gender-affirming surgery, many participants spoke about the support and information they gained through connecting with other TNB people in person or through online networks. Participants who underwent surgery at hospitals that specialized in gender-affirming surgery reflected on the validation of meeting many other TNB patients “going through the same thing” (participant 2, trans man, he/him) and valued the ability to discuss concerns or ask questions (Table 2, quotes 18–20). Those who underwent surgery at other hospitals did not have the same exposure to other TNB patients and did not describe the same sense of community support (Table 2, quotes 21 and 22).

### Impact of interactions with health care professionals

Participants described encounters ranging from ignorance to ridicule (Table 2, quotes 23 and 24), as well as feeling their health care professionals “don’t have the interest or confidence to take on” their health care (participant 4, male, he/him). Several participants relayed frustration with lost referrals or unreturned phone calls from physicians’ offices, perceiving that their gender was the reason for these mistakes (Table 2, quotes 25 and 26). Often, participants described an expectation that health care professionals would be transphobic (intentionally or not), as evidenced by their surprise when they encountered health care professionals who were welcoming and affirming of their identity (Table 2, quote 27). This high emotional investment, combined with the previously mentioned barriers, led to increased anxiety in health care settings. In addition to misgendering, participants described mistreatment by health care professionals who dismissed health concerns and inappropriately fixated on aspects of their transition or gender identity (e.g., questioning patients about aspects of their health unrelated to their presenting concern; Table 2, quotes 28 and 29).

Transparent communication and a willingness to learn, especially without any expectation for the participant to educate the health care professional, contributed a feeling of safety and improved trust between participants and health care professionals. Examples of health care professionals acting as allies included acknowledgement and commiseration regarding the challenges involved in accessing gender-affirming care or gender-affirming surgery, and correcting other health care professionals who misgendered participants, especially when the provider was unaware that the participant could hear their conversation (Table 2, quotes 30 and 31). Participants appreciated when perioperative care professionals took the time to explicitly acknowledge the emotional importance of gender-affirming care and vulnerability they often experienced. Perioperative care professionals who displayed genuine enthusiasm and excitement when participants were undergoing gender-affirming surgery made an especially strong impression (Table 2, quote 32). These positive interactions led participants to be more confident in advocating for their own or community needs around gender-affirming care.

## Interpretation

Our findings illustrate challenges to address in both the perioperative setting and the health care system overall. For participants in the study, the stress of negotiating presurgical bureaucracy often stood in sharp contrast to the positive feelings they experienced when deciding to seek gender-affirming surgery. Participants described the need to self-advocate when interacting with health care professionals who had a lack of experience with or negative attitude toward TNB people. All the major themes described had an underlying sentiment of a struggle to fit within a system that was not designed for TNB people. In the perioperative context, patients of any background may experience some degree of anxiety, fear, or frustration. However, a community that has been historically marginalized is likely to experience additional stress. As previously mentioned, TNB people experience stigmatization, discrimination, and marginalization within the hospital environment and the broader societal context. They often experience trauma as a result.3,4,6

Trauma-informed care describes an approach that “realizes the widespread impact of trauma and understands potential paths for recovery; recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system; and responds by fully integrating knowledge about trauma into policies, procedures, and practices, and seeks to actively resist retraumatization.” 32 A trauma-informed approach follows 6 key principles, namely safety; trustworthiness and transparency; peer support; collaboration and mutuality; empowerment, voice, and choice; and cultural, historical, and gender issues.32 The principles of trauma-informed care are widely applicable throughout health care, including the perioperative context, where people are inherently in a state of vulnerability. Participants relayed traumatic experiences and some explicitly stated a desire for a more widespread trauma-informed approach within health care systems.

Although our study was focused on the perioperative period, all participants described barriers in accessing gender-affirming care before the perioperative period, including surgical experiences that were unrelated to gender. Makhoul and colleagues10 highlighted the importance of gender-affirming surgery as a major life event with unique barriers that must be addressed, including education for health care professionals, creation of safer care environments (i.e., multidisciplinary gender-affirming clinics), and policy changes. Chang and colleagues33 described the impact of misgendering on the perioperative experience for patients after gender-affirming surgery. Although these studies were in the US — with a different health care system, legal system, and political landscape — we found similarities. Our findings highlight the need for health care professionals to receive education specific to working with TNB patients and providing safe and competent gender-affirming care throughout the perioperative context.

Interprovincial differences in requirements to access gender-affirming care can create challenges for TNB people who may move in the midst of receiving gender-affirming care. Moving to a new province typically necessitates restarting a lengthy process. The World Professional Association for Transgender Health (WPATH) updated their standards of care in 2022 and now suggests only a single opinion from a health care professional before initiation of gender-affirming medical and surgical care in adults.1 They suggest a duration of 6 months of hormone therapy before gonadectomy, while acknowledging that “hormones are not clinically indicated for [TNB] adults who do not want them.”1 As of January 2024, only 3 provinces or territories in Canada have current and easily accessible websites outlining requirements for accessing gender-affirming surgery that are up to date with the current WPATH standards of care (Table 3).

View this table:
[Table 3:](http://www.cmaj.ca/content/196/24/E806/T3)

Table 3: 
Provincial requirements for gender-affirming surgeries for adults

Our data show gaps in Canada’s health care systems, with TNB people reporting that they did not experience a safe environment. The WPATH suggests that “institutions involved in the training of health professionals develop competencies and learning objectives for transgender and gender diverse health within each of the competency areas for their specialty.”1 Our data support the development and inclusion of transgender health competencies at all levels of medical training. Along with efforts to increase knowledge among health care professionals, policy changes should be implemented to increase access to transgender-competent care that aligns with the most current WPATH guidance for standards of care. This requires advocacy at several levels, including provincial and federal legislation.

### Limitations

We recruited participants who identify as TNB, so we may have inadvertently excluded people who are not cisgender but do not identify as transgender or nonbinary. Although the word “transgender” can be seen as an umbrella term that includes all gender identities other than cisgender, the choice of language in this realm can be deeply personal and it may not be possible to use terminology that is universally agreed upon. Despite our attempts to recruit participants from diverse backgrounds and perspectives, most participants were English-speaking, White transgender men from Nova Scotia. Snowball sampling inherently has the potential to reach people who share similar characteristics, which could contribute to this relative lack of diversity. Much of our recruitment was achieved via Internet-based social media, possibly excluding participants without access. Most surgical experiences described by participants involved gender-affirming surgery, which may be a unique perioperative experience from instances when the surgery in question is unrelated to gender. The barriers to accessing gender-affirming care and gender-affirming surgery overshadowed participants’ experiences to the extent that recollection and discussion of the remainder of the perioperative period were more limited. Conducting video interviews, instead of in-person interviews, represents another limitation, as nonverbal cues may be missed in this format. However, given the cross-country recruitment of our study and the ongoing pandemic, in-person interviews were not feasible.

### Conclusion

Barriers to accessing safe, inclusive perioperative care for TNB people in Canada persist. Participants faced challenges in accessing gender-affirming care, regardless of whether they were ultimately seeking gender-affirming surgery, which overshadowed much of their overall experiences with health care systems. They often self-managed their care and educated their providers in health care situations, including the perioperative environment. Our data support the need for more in-depth and nuanced discussions surrounding shared decision-making, and consideration of potential effects of past traumas, instances of invalidation, or negative interactions within health care. Trauma-informed care principles may be especially valuable in TNB care. Future research on the development of role-specific educational content and competencies should incorporate an explanation of the various roles within the perioperative team and involve direct input from TNB community members.

## Footnotes

*   Competing interests: Hilary MacCormick is a volunteer member of the Canadian Anesthesiologists’ Society Diversity, Equity, and Inclusion committee. Gianni Lorello reports funding from the Canadian Institutes of Health Research, the Social Sciences and Humanities Research Council of Canada, the University of Toronto, and the Royal College of Physicians and Surgeons of Canada. Ronald George is an associate editor with the *Canadian Journal of Anesthesia* and trustee with the Canadian Anesthesia Research Foundation. No other competing interests were declared.

*   This article has been peer reviewed.

*   Contributors: All of the authors contributed to the conception and design of the work. Hilary MacCormick, Les T. Johnson, Drew Burchell, and Allana Munro contributed to data acquisition, analysis, and interpretation. Hilary MacCormick, Les T. Johnson, and Drew Burchell drafted the manuscript. All of the authors revised it critically for important intellectual content, gave final approval of the version to be published, and agreed to be accountable for all aspects of the work.

*   Funding: Funding was received from the Department of Anesthesia, Pain Management, and Perioperative Medicine, Dalhousie University.

*   Data sharing: Data will not be shared to protect the confidentiality of our participants.

*   Accepted April 23, 2024.

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) licence, which permits use, distribution and reproduction in any medium, provided that the original publication is properly cited, the use is noncommercial (i.e., research or educational use), and no modifications or adaptations are made. See: [https://creativecommons.org/licenses/by-nc-nd/4.0/](https://creativecommons.org/licenses/by-nc-nd/4.0/)

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