Review highlights essential neurological considerations for gender dysphoria care

Gender dysphoria involves distress caused by a mismatch between a person's gender identity and sex assigned at birth. Gender-affirming care may include hormone therapy and surgery. However, neurosurgeons often report limited confidence in treating transgender patients because of gaps in knowledge about the neurological implications of gender dysphoria and hormone therapy. To address this gap, researchers from the Royal Infirmary of Edinburgh reviewed existing literature to identify these implications and improve neurosurgical care.

Gender dysphoria is a psychiatric condition characterized by distress due to a mismatch between the gender assigned at birth (based on external genitalia) and the self-perception of gender. Meanwhile, transgenderism is a generalized term used to describe a similar condition but may or may not involve the distress component. The incidence of gender dysphoria has gradually increased, especially among children and adolescents. Individuals with gender dysphoria seek various treatments, including gender-affirming hormone therapy (GAHT), psychotherapy, and surgery. However, these treatments are associated with several adverse effects. Neurosurgeons have decreased confidence in managing gender dysphoria owing to their limited knowledge and awareness of neurological implications associated with the condition and its treatment.

To improve this awareness, Dr. Rajdeep Brahmachari and Dr. Chandrasekaran Kaliaperumal from the Royal Infirmary of Edinburgh reviewed the literature on the neurological considerations of gender dysphoria. This review was published in Volume 12 of the Chinese Neurosurgical Journal in September 9, 2026. Commenting on the rationale for the study, Dr. Kaliaperumal remarked, "Gender dysphoria and its treatment are associated with several neurological issues. Effective management can be achieved by improving the knowledge of neurosurgeons. Therefore, we reviewed the literature to clarify neuroanatomical variations, neurological and neurosurgical risk factors, and perioperative, neuroanesthetic, and neuropsychiatric considerations, enabling evidence-based holistic neurosurgical care."

The authors analyzed published articles retrieved from various sources, including public databases. The anatomical features of the brains of transgender individuals resembled the self-identified gender rather than those of the assigned gender, including increased cortical thickness and weak connections in regions involved in processing body perception. Gender-affirming treatment can also lead to physiological changes. For example, GAHT increases gray matter density, volume and the risk of headaches, benign tumors (meningioma and prolactinoma), intracranial hypertension, stroke, and epilepsy.

Individuals with gender dysphoria are hesitant to seek surgical treatment owing to stigma, social isolation, and prejudice. To mitigate this hesitancy, neurosurgeons must utilize inclusive language while communicating and document pre-surgical GAHT duration. Patients must be informed about the benefits and risks of the surgery and encouraged to seek advice from a mental health professional for further clarity. Neurosurgeons can increase patient comfort by recording the preferred gender identity and pronouns along with the details of previous or ongoing GAHT before surgery.

The preoperative risks of neurosurgery include viral and bacterial infections. The increased prevalence of stress, anxiety, and depression among transgender individuals may predispose them to smoking, alcohol consumption, and drug abuse, increasing perioperative risks. Transgender individuals are also predisposed to metabolic disorders, such as diabetes and insulin resistance. Thus, neurosurgeons must account for preoperative and perioperative risks to mitigate adverse events. Sedation during surgery is an important consideration. Anti-seizure medications, corticosteroids, and neuromuscular blockers may exhibit interactions in individuals undergoing hormonal therapy before surgery.

Thus, perioperative neuromuscular monitoring is warranted when the neurosurgery involves the use of neuromuscular blocking agents. Intraoperative risks are especially evident in patients with human immunodeficiency virus infection. Antiviral drugs may interact with hypnotics, anxiolytics, and antibiotics. As GAHT can induce hematological changes, intraoperative blood transfusion must be considered. Surgery may also involve respiratory risks for individuals with gender dysphoria, especially in transmen who use breast-binder garments. Meanwhile, intubation is a concern in transwomen who have undergone laryngeal surgery. Special considerations are warranted for urinary catheterization in individuals who have previously undergone gender-affirming surgery.

When preferred, private rooms can enhance patient privacy and comfort after surgery. Healthcare personnel attending the neurosurgical patient can mitigate psychosocial stress by addressing the patient with preferred names and pronouns and effectively managing wounds and scars. The implementation of a multidisciplinary approach for pain management can improve surgical outcomes. Commenting on the importance of this review, Dr. Brahmachari states, "Our review summarizes the medical and psychosocial implications of neurosurgery for individuals with gender dysphoria. Proactive training for neurosurgeons and healthcare personnel can improve the outcomes of neurosurgery in these individuals."