What considerations are necessary when caring for a transgender patient with perforated diverticulitis?

Caring for a Transgender Patient with Perforated Diverticulitis

When caring for a transgender patient with perforated diverticulitis, the surgical management follows identical clinical algorithms as for cisgender patients—urgent Hartmann's procedure with broad-spectrum antibiotics for pneumoperitoneum and abscess—while simultaneously implementing transgender-specific care protocols including correct pronoun usage, documentation of sex assigned at birth and organ inventory, trauma-informed communication, and awareness that this population faces higher pain burden and healthcare discrimination that may affect postoperative outcomes. 1, 2

Immediate Surgical Management (Identical to Cisgender Patients)

The presence of pneumoperitoneum from perforated sigmoid diverticulitis mandates urgent surgical intervention with Hartmann's procedure as the recommended approach given the combination of pneumoperitoneum and abscess formation. 1

Surgical Decision Algorithm:

• Hartmann's procedure (sigmoid resection with end colostomy) is indicated for patients with pneumoperitoneum, abscess, and any of the following: hemodynamic instability, immunocompromised state, feculent peritonitis, or significant comorbidities. 1, 3
• Primary resection with anastomosis may only be considered in highly selected hemodynamically stable patients without major comorbidities, but Hartmann's remains safer in real-world practice. 1
• Damage control surgery (limited resection, peritoneal lavage, temporary closure, ICU resuscitation, second-look operation) is reserved for physiologically deranged or hemodynamically unstable patients. 1, 4

Immediate Antibiotic Therapy:

• Initiate broad-spectrum IV antibiotics immediately covering anaerobes and gram-negatives: Meropenem, Doripenem, Imipenem/cilastatin, or Eravacycline. 1
• Duration: 4 days if adequate source control in immunocompetent, non-critically ill patients; up to 7 days if immunocompromised or critically ill, guided by clinical response and inflammatory markers. 1, 4

Critical Surgical Pitfalls to Avoid:

• Do not attempt non-operative management with large amounts of distant free gas or clinical peritonitis—failure rates approach 57-60%. 1
• Do not perform primary anastomosis in unstable patients or those with fecal peritonitis, as this significantly increases mortality. 1
• Do not rely on laparoscopic lavage as definitive treatment—reoperation rates are unacceptably high. 1

Transgender-Specific Care Considerations

Documentation and Communication (Critical First Steps):

Immediately upon encounter, implement the two-step gender identification process and document correctly in the electronic health record:

• Ask about sex assigned at birth (not "biological sex" or "natal sex"—these terms are stigmatizing). 2
• Ask about current gender identity and pronouns after sharing your own. 2
• Ask about organ inventory (what anatomy is present, whether patient has had gender-affirming surgeries). 2
• Use the patient's affirmed name and pronouns consistently throughout all documentation and verbal communication. 2

Trauma-Informed Approach to Physical Examination:

Transgender patients have experienced significant healthcare discrimination—23% avoid medical care when needed due to fear of mistreatment, and 33% report negative healthcare experiences related to their gender identity. 2

Specific examination considerations:

• Offer a chaperone for physical examinations, but allow the patient to decline. 2
• Explain each step of the examination before performing it, particularly for genital or sensitive areas. 2
• Recognize that 50% of transgender patients have had to educate their providers about transgender care, creating additional burden during acute illness. 2
• Avoid stigmatizing language: never use "biologically male/female," "transgenders," "transvestite," or "transgenderism." 2

Perioperative Pain Management Considerations:

Transgender patients experience disproportionately higher rates of chronic pain and poorly managed pain compared to cisgender populations, related to socioeconomic disparities, discrimination, and minority stress. 2

Postoperative pain protocol adjustments:

• Provide aggressive multimodal pain control recognizing baseline higher pain burden in this population. 2
• Screen for pre-existing chronic pain conditions which are more prevalent in transgender patients. 2
• Address socioeconomic barriers that may affect access to postoperative pain medications or follow-up care. 2
• Consider intraoperative use of clonidine, dexmedetomidine, droperidol, or promethazine for enhanced pain control. 2

Gender-Affirming Hormone Therapy Considerations:

If the patient is on hormone therapy, do not discontinue estrogen or testosterone perioperatively unless there are specific contraindications. 5

Estrogen therapy (transwomen) considerations:

• Oral estrogen may carry higher thrombosis risk than transdermal/peripheral administration, particularly with genetic mutations, smoking, or prolonged inactivity. 5
• Weigh thrombosis risk against surgical stress and consider temporary dose adjustment or route change in consultation with the patient's hormone prescriber. 5
• Postoperative immobility increases thrombotic risk—ensure aggressive DVT prophylaxis. 5

Testosterone therapy (transmen) considerations:

• Testosterone appears to carry fewer perioperative risks than estrogen. 5
• Continue testosterone through the perioperative period unless specific contraindications exist. 5

Anatomical Considerations for Surgical Planning:

Obtain organ inventory before surgery to understand what anatomy is present:

• Transwomen who have undergone vaginoplasty have neovaginal anatomy in close proximity to the rectosigmoid. 2
• Transmen who have undergone hysterectomy may have altered pelvic anatomy. 2
• Ask directly: "What surgeries have you had? What organs are present?" rather than making assumptions based on appearance. 2

Postoperative Care and Discharge Planning:

Address structural barriers that disproportionately affect transgender patients:

• Lower socioeconomic status is more common in transgender populations—assess ability to afford medications, transportation to follow-up, and home care needs. 2
• Screen for social support systems, as transgender patients may have strained family relationships and lack traditional support networks. 2
• Provide clear written instructions and ensure the patient has access to follow-up care with providers knowledgeable about transgender health. 2

Stoma Care Considerations (If Hartmann's Performed):

Recognize that 20-50% of patients after Hartmann's procedure never undergo reversal, and this may have particular psychosocial impact on transgender patients related to body image and gender dysphoria. 3

• Involve ostomy nursing specialists early and ensure they use correct pronouns and affirming language. 2
• Address potential gender dysphoria related to stoma placement and body changes with sensitivity. 2
• Discuss timeline for potential reversal (typically 6 months) and factors that may affect candidacy. 3

Common Pitfalls in Transgender Patient Care:

• Assuming gender identity based on appearance—always ask. 2
• Using incorrect pronouns or deadname (birth name patient no longer uses) in documentation or conversation. 2
• Focusing excessively on transgender status when it is not relevant to the acute surgical problem. 2
• Failing to recognize higher baseline pain and healthcare avoidance in this population. 2
• Discontinuing hormone therapy unnecessarily without consultation. 5

Team Communication:

Brief all team members (nursing, anesthesia, surgical team, ICU staff) on:

• Correct name and pronouns to use consistently. 2
• Organ inventory relevant to surgical planning. 2
• Recognition that this patient population has experienced healthcare discrimination and requires trauma-informed care. 2