With greater media exposure, the power of social media, and transgender celebrities such as Caitlyn Jenner sharing her experiences, attitudes towards the transgender community around the world are changing, and I as an aesthetic practitioner am, slowly, seeing the effects. Although it’s still not a daily or even weekly occurrence, transgender patients are seeking non-invasive body contouring aesthetic treatments that can help their physical appearance match the way they view themselves.
In many cases, patients who present to clinic have already had their sex reassignment surgery or are on a waiting list to have one. There are a number of sex reassignment surgeries that patients will encounter while transitioning. Feminisation surgeries can include vaginoplasty, augmentation mammoplasty, orchiectomy, facial feminisation surgery, reduction thyroid chondroplasty (tracheal shave) and voice feminisation surgery, among others. Masculinisation surgeries may include chest masculinisation, metoidioplasty, phalloplasty, scrotoplasty, and hysterectomy.1
It is usually the case that after performing ‘top surgery’, some patients wait years before the next surgical step of ‘bottom surgery’ to alter their genitals. Although I am not a plastic surgeon and gender reassignment surgery is not what I do, I have experience in supporting the process with non-invasive and minimal-risk body contouring procedures. These body sculpting and contouring procedures help to enable patients to be satisfied that their physical appearance matches their inner sense of self. In my experience, it is more common to see female to male patients rather than male to female as they generally require more surgical treatments.
My experience with the transgender patients I have seen is that they are more than certain about what they want to achieve and have, in many cases, been waiting for a very long time to achieve their final results. My patients have known from their early teens that they weren’t comfortable in their own skin, yet they were forced to wait until they could do anything about it, which is often due to long waiting lists on the NHS and the financial implications associated with private treatment. If they initially sought help on the NHS, they’d have typically waited for up to two and a half years just to get an initial consultation at the gender identity clinic (GIC).2 When consulting these patients, the first thing I do is listen. It’s imperative to talk to transgender patients about what they need and their desired result; actually, I do this with all of my patients.
As a trained psychiatrist, I rely on my NHS background and experience to help me understand what’s driving the decision for gender body contouring. I also work to manage expectations about what I can and cannot achieve with machines. In general, the female to male patients I have seen are looking to achieve a straighter, more masculine body contour. Generally, they want work on their abdomen, waist, love handles (lower waist and back), hips, buttocks, and thighs. Frequently, many transgender men have been exercising extensively, taking testosterone and weight lifting in order to achieve a more masculine shape, but they are not getting the results they are looking for. Non-invasive body contouring works well in these cases. Male to female patients, on the other hand, generally seek a more hourglass figure, with the creation of a waist and hips through surgical fat grating procedures. Typically, the body contouring that I do, involves a combination of cryolipolysis techniques and other machines to help reshape the body’s contours and create a more feminine or masculine appearance. I use the CoolSculpting machine to address fat and the Emsculpt to achieve better muscle definition.
Case study 1
A patient registered with the clinic who was undergoing a female to male transition. My colleagues would have never imagined that we were treating a transgender patient. It was only during an extended, one-to-one consultation that my patient revealed his transition, and asked for confidentiality (I therefore did not discuss the case even with my assistant). As we know, male and female bodies have different shapes and typically, male bodies are less curvaceous than female bodies. Aside from breasts, nowhere is this more apparent than in the buttocks and hips. In this particular case, the area of concern was the hips. The original body shape was that of a pear and despite him already undergoing ‘top surgery’ (breast augmentation and chest masculinity surgery), as well as hormonal treatment, there was still a very prominent fat bulge on the outer thighs. I treated this area with two cryolipolysis procedures, eight weeks apart using CoolSculpting. The patient was very happy with results as it achieved a more athletic, masculine look.
Case study 2
Although this case was not a transgender transitional patient, but a female patient who was trying to achieve de-feminisation of her body, I think it is an interesting case. During the consultation, it came to light that even though the patient was a heterosexual woman, she was aiming to achieve an athletic body with very little signs of femininity, without the typical curves we associate with female bodies. This was a challenge for me as I generally work to an ‘hourglass’ shape for my female patients as, typically, it’s the most requested.
I informed her that I would be assessing her for signs of body dysmorphic disorder, as it was an unusual request. We also discussed transgender tendencies – my psychiatry experience was helpful here – however, as assessment went on, it became clear that despite not transitioning, she had a preference for athletic shape and I thought that this should be respected. This highlights the importance of an empathetic and non-judgmental approach to consulting patients. I performed a non-invasive de-feminimisation treatment using cryolipolysis, which reduced the patient’s waistline and equalised the waist to hip ratio. This consisted of a single treatment of four applications.
Transitioning is a frequently long and painful process, and I have a great deal of compassion for the transgender patients I see. Their desire and need goes far beyond the slim socialite looking to eradicate the faintest hint of a bingo wing. The reality for me is if I can help my transgender patients feel happier and confident as they go through life with non-invasive body contouring treatments, then that in itself brings me the greatest of joy. It’s the least I can do for them.
My top tips for treating transgender patients
- DON’T patronise. If you are a cisgender person, you may never truly be able to understand the perspective of a transgender patient. However, you can try your best by listening to them. Don’t be afraid to ask them about the journey that brought them to you.
- DON’T address them by the wrong gender pronoun. Right from the beginning, ask them how they prefer to be addressed and do that all of the way through.
- DO give direct and honest advice. At all times, never judge.
- DO let them see you as their partner and collaborator. You are there to help them in whatever ways you can to achieve a physical appearance that most closely resembles who they are inside.
- DO set realistic expectations. Aesthetic practitioners have great capability, however, we are not able to turn everyone into their favourite celebrity, so ensure they understand the limitations.
- NHS, Gender Dysphoria (UK: NHS, 2019) <https://www.nhs.uk/conditions/gender-dysphoria/treatment/>
- BBC, Transgender people face two-year wait for NHS appointment (UK: BBC, 2018) <https://www. bbc.co.uk/news/uk-england-42774750>
- Lane M, Ives G, Sluiter E et al., Trends in Gender-affirming Surgery in Insured Patients in the United States, Plastic and Reconstructive Surgery, 2018
- Nutt A, Transgender surgeries are on the rise, says first study of its kind, The Washington Post, 2018 <https://www.google.co.uk/amp/s/www.washingtonpost.com/amphtml/news/to-your-health/ wp/2018/02/28/transgender-surgeries-are-on-the-rise-says-first-study-of-its-kind/>
- Petter O, Gender reversal surgery is more in-demand than ever before, The Independent, 2017 <https://www.google.co.uk/amp/s/www.independent.co.uk/life-style/gender-reversal-surgery-demand-rise-assignment-men-women-trans-a7980416.html%3famp>
- Mathy R, On cultural competence and scientific rigor in transgender treatment, American journal of public health, 2004
- Horn S, Kosciw J et al., Special issue introduction: New research on lesbian, gay, bisexual, and transgender youth: Studying lives in context, Journal of Youth and Adolescence, 2009
- Bradford A, What does ‘transgender’ mean?,Live Science, 2018 <https://www.google.co.uk/amp/s/ amp.livescience.com/54949-transgender-definition.html>