Illustration of two people receiving blood transfusions in their arms on a background of the transgender flag.
Current epidemiologic data shows that there are 1 million adults and youth that identify as transgender in the US
Today's Clinical Lab/iStock,Svetlana Krivenceva

Guidelines Must Change to Make Transfusion Medicine Gender Inclusive

Current blood transfusion guidelines pose significant concerns for transgender and nonbinary people and need to be updated

Photo portrait of Carlo Ledesma, MS, MLS(ASCP)SH, DLM, QLS, MLS(AMT)
Carlo Ledesma, MS, MLS(ASCP)SH, DLM, QLS, MLS(AMT)

Carlo Ledesma, MS, MLS(ASCP)CMSHCM, QLSCM, DLMCM, MT(AMT) is a doctor of clinical laboratory science (DCLS) resident at Oklahoma City VA Medical Center,...

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Published:Dec 19, 2022
|Updated:Jan 16, 2023
|3 min read
          Photo portrait of Carlo Ledesma, MS, MLS(ASCP)CMSHCM, QLSCM, DLMCM, MT(AMT)
Carlo Ledesma, MS, MLS(ASCP)CMSHCM, QLSCM, DLMCM, MT(AMT), is a doctor of clinical laboratory science resident at Oklahoma City VA Medical Center and specializes in hematology and

Why do current transfusion medicine guidelines and recommendations need to be updated?

Other than changing the guidelines to promote equity and inclusion of care, the current guidelines in emergency transfusion of uncrossmatched O RhD-negative red blood cells, also known as O- blood, need to be updated for patient safety and to ensure that rare O RhD-negative blood is preserved for patients that need it the most without causing any harm.

Specifically, current epidemiologic data shows that there are 1 million adults and youth that identify as transgender in the US, a significant increase from 2009 estimates of 115,000 to 450,000. There is no better time than now to update current transfusion medicine guidelines to ensure equitable safety in transfusion practices. As leaders in laboratory medicine, medical laboratory professionals should be the instruments of change to eliminate health disparities among transgender individuals. Using our expertise in laboratory medicine, we can influence clinical decisions, ensuring health care equity for a population that historically has had poor health outcomes.

What are the major concerns around transfusions for transgender and non-binary people?

The current US guideline states: “Don't transfuse O-negative blood except to O-negative patients and in emergencies for women of childbearing potential with unknown blood group” and is also supported by the UK National Health Service's guidelines from 2009.

The guidelines were structured to ensure rare blood products such as O RhD-negative blood, also known as O- blood or universal donor blood, are conserved for patients who are rapidly exsanguinating and desperately need these life-saving red blood cells, while reducing the risk of D alloimmunization in these patients, which occurs when an RhD-negative person exposed to D-positive red blood cells develops anti-D antibodies. Reducing the risk of D alloimmunization is critical for women of childbearing age because of the complications brought on with the formation of anti-D antibodies that can harm the patient or their child.

Phenotypic presentation of patients who have undergone estrogen or testosterone therapy is not adequate to support clinical decisions, especially in trauma cases or in rapidly exsanguinating patients who need transfusion support. 

A 2018 study that surveyed men who self-identified as transgender found that transgender men can experience pregnancy, even after transitioning socially and hormonally. Thus, previous sensitizing events through pregnancy or transfusion can lead to anti-D antibodies in transgender men. Given this information and the understanding that D alloimmunization is estimated to occur in about 42 percent of people, the current recommendations to give men O RhD-positive blood can harm transgender men through potential hemolytic transfusion reactions to O RhD-positive blood, including potentially harming unborn children from hemolytic disease of the newborn.

In contrast, the risk of D alloimmunization and complications remains low for transgender women, and the use of O RhD-negative red blood cells in this patient population would be a waste of a rare and valuable resource.

How can changing transfusion guidelines help manage scarce blood products?

Group O RhD-negative red blood cells (RBCs) are a scarce blood product used for emergency transfusions and are the only available transfusion support for neonates. While O RhD-negative blood is a critical resource, only 7 percent of the US population are universal blood donors. Combined with the abysmally low blood donor rate of 3 percent in the US, this incredibly scarce resource must be managed carefully.

The guideline also needs to be revised to ensure that transfusion practices are engaged and compliant. A practice survey on the use of group O red blood cells revealed that 63 percent of participating hospitals do not comply with the current standards for using group O RhD-negative red blood cells, where hospitals have provided group O RhD-negative red blood cells to patients regardless of sex.

Moreover, usage practices such as single-unit transfusion should also be reexamined, including developing laboratory policies to rapidly identify ABO/Rh compatible red blood cells to help conserve rare blood products and direct safe transfusion practices.