Gender reassignment and neurosurgical implications: a narrative review

Gender dysphoria is characterized by a marked incongruence between an individual's experienced gender and assigned sex at birth. The global prevalence of transgender individuals is increasing, leading to greater interaction with healthcare systems across multiple specialties, including neurosurgery. Gender-affirming hormone therapy (GAHT), a cornerstone of treatment, has several neurological and neurosurgical implications. Nevertheless, neurosurgeons often report limited confidence in managing transgender patients because of insufficient awareness and training. This review explores the growing evidence of the broad neurobiological basis of gender identity, which involves variations in neuroanatomy and its contribution to the pathophysiology of gender incongruence. Moreover, the understanding of the neurovascular and neuropsychiatric effects of GAHT has provided a broad picture of the conditions under which a transgender patient can present to the neurosurgical outpatient department or emergency department. The review also discusses a holistic neurosurgical care plan for transgender patients (including gender dysphoria), which involves making a safe and conducive environment for the patient to open up during consultation, a proper method to obtain informed consent on the basis of the WPATH SOC 8 guidelines, and the identification of general and specific risk factors during the perioperative period and the subsequent optimization. Furthermore, this review identifies the factors that may affect proper intraoperative care such as anesthetic and antiviral drug interactions with GAHT hormonal agents, patient positioning and preparation issues, and thromboprophylaxis. This review provides an outlook for optimum postoperative care involving comfortable patient recovery for proper wound healing, pain management, and mental health support. In conclusion, transgender patients present unique challenges in neurosurgical practice owing to the combined effects of GAHT and psychosocial determinants. There is a critical need for improved education, inclusive clinical practices, and multidisciplinary collaboration to optimize patient outcomes. Further large-scale studies are needed to strengthen the evidence base and guide standardized neurosurgical care for this population.