Treating Transgender Patients

By Dr Rekha Tailor / 15 Feb 2019

Aesthetic practitioner Dr Rekha Tailor gives an overview of the most popular treatment options for transgender patients

The process of an individual changing their gender presentation so that it aligns with their internal sense of gender identity is called ‘transitioning’. It is difficult to confirm how many individuals identify as transgender in the UK as there is currently no census that captures data regarding gender identity. However, The Gender Identity Research and Education Society (GIRES) estimates that about 1% of the British population are gender non-conforming to some degree.1 It is generally accepted that the increase in visibility of the transgender population over recent years means that this number will invariably continue to rise – a statement that is certainly supported with the statistic that referrals to adult gender identity clinics across the UK have increased dramatically over the past 10 years.2 Given this rise, it is reasonable to assume that the number of transgender individuals seeking aesthetic procedures specific to their individual transitioning journey will also increase, and we as aesthetic practitioners need to ensure we are well educated and equipped to deal with their needs.

This article aims to address the specific considerations that aesthetic practitioners should take into account when treating transitioning patients to ensure that both their dermatologic and emotional needs are met in order for them to make a successful physical and emotional transition throughout the process.

Initial consultation

It is a privilege to work in an industry that allows you the opportunity to really make a difference to your patients at every single stage of their treatment experience. In my experience working with transgender patients, I have found that this is particularly true as their personal journeys can hold another layer of meaning. The initial consultation process is important with any patient, but particularly so with one who is transitioning. A report commissioned by the LGBT Foundation found that 80% of transgender people experience anxiety before accessing hospital treatment due to fears of insensitivity, misgendering and discrimination, with intimate care causing the most concern. Misgendering and inappropriate questioning were found to be some of the key causes of dissatisfaction.3 This highlights how imperative it is that aesthetic practitioners are fully aware of all aspects of the transitioning process and are also completely committed to building a relationship of understanding and trust between them and their patient through the promotion of education, safety and clinical excellence. This allows the patient to be confident that they have been dealt with sensitively and that they are being cared for.

The transitioning process is a complex one and transgender patients may face unique dermatologic requirements in addition to routine care. It is important for practitioners to recognise that every transitioning journey is unique to the individual involved and that there are very specific considerations that need to be made when treating these patients as opposed to other individuals. It is also important to recognise the emotional impact of a transitioning journey and that there is no uniform approach. No assumptions about the patient should be made. 

For some patients, the process is something that’s happened over a short period of time, but for others it’s been a lengthy process that has taken years, possibly decades to come to the stage of the journey that they are at when they are first introduced to you. Therefore, it’s incredibly important to make that first meeting between patient and practitioner count as, whatever the circumstances, I have found that the patient usually feels quite vulnerable. This also gives you a good opportunity to discuss a treatment plan, as well as different needs and considerations in detail, which are explored below.

Management of hormone-related changes

Hormone therapy tends to be the first step for most adult transgender people who are in the process of transitioning. Masculinising hormones (testosterone) and feminising hormones (oestrogen) will usually need to be taken indefinitely and both have notable effects on the skin and hair that can be treated effectively within a credible aesthetic clinic.

Hormone therapy in transgender women (male to female) will generally result in a partial reduction in quantity and density of body and facial hair. However, it is unlikely that hair will be eliminated, and this is often an area that individuals feel they would like addressed. The most common aesthetic hair removal processes are laser hair removal (LHR), intense pulse light (IPL) and electrolysis. At my clinic Health & Aesthetics, LHR is one of the most popular treatments we offer. Although results can vary between individuals, on average, individuals in my clinic see up to a 60-80% reduction in hair growth after six to eight treatments with maintenance required one to two times a year. In addition to hair reduction, oestrogen from hormone therapy rapidly reduces sebum production that can result in itching and dry skin.5,6 This requires intense hydration using skin stabilisers to reduce inflammation and itch.

It is common for a transgender man (female to male) experiencing masculinising hormone therapy to experience increased sebum production caused by the dramatic increase in testosterone. This effectively mimics a second puberty and can often lead to an array of skin conditions that include acne vulgaris, acne scarring and post-inflammatory hyperpigmentation.6 In my clinic, suggested treatments for the successful management of each condition include, but are not limited to:

  • Laser treatment with contact cooling and vacuum technology to treat acne vulgaris safely and effectively
  • Hydrafacial (also known as hydradermabrasion) – a non-invasive, soothing and non-irritating treatment for acne that removes dead skin and impurities leaving the skin smooth and radiant
  • Laser skin rejuvenation – ideal for eliminating areas of hyperpigmentation
  • Ablative fractionated laser – a new generation of fractional skin resurfacing that can reduce the appearance of pigmentation and scarring
  • Topical skincare treatments designed to significantly improve skin health and appearance

It is also likely that transgender men will experience male-pattern baldness (MPB) due to hormone therapy.6 Also known as androgenetic alopecia and genetic hair loss, MPB can be an unwanted and extremely difficult side effect of hormone therapy to cope with emotionally. At Health & Aesthetics, we advocate and offer a combination therapy that includes three to five sessions of platelet-rich plasma (PRP) in the scalp. Treatments are carried out every four to six weeks. PRP is component of the blood that contains special proteins, known as growth factors. These growth factors aim to stimulate the activity of the hair follicles and promotes new hair growth. This is combined with a course of tablets that contain marine proteins and vitamins to stimulate hair growth across the scalp.7 This is a completely drug-free treatment which can boost hair growth and volume, resulting in thicker, longer and fuller hair for both men and women.8

Management of surgery-associated changes

Breast augmentation in transgender women or removal surgery for transgender men will often result in scarring which can be unsightly, restrict movement or can be painful and itchy. For some individuals, they can also be an unwanted visible reminder of their previous gender identity. The appearance of surgical scarring can usually be improved by using a combination of the aforementioned non-surgical resurfacing technique using ablative fractionated lasers or an advanced fractionated CO2 laser treatment that works more effectively on heavier surgical scarring than traditional resurfacing methods, and topical treatments that contain ingredients that will actively encourage cell renewal and hydration to soften and smooth the scar area (such as retinols).9

Management of facial transformation

An emerging role for aesthetic practitioners in the physical transformation of transgender patients relates to facial transformation. I find this is an area that transgender women, in particular, feel that they need to address in their transitioning journey. Traditionally, male and female faces differ in several ways. Broadly speaking, the female face typically has a flatter forehead, smaller nose, and more prominent cheekbones, plumper lips and a small chin, whilst the male face has a broad well-defined jaw, prominent chin and nose and wider, thinner lips.10 Cosmetic surgery to achieve the desired results can often be extremely invasive and carry huge expense which rules it out as a viable option for many patients. Taking this into consideration, many individuals opt for a more non-invasive approach to feminise or masculinise the face in a subtler way. This can involve the use of botulinum toxin in the upper face to give the appearance of a flatter forehead and open eyes, or dermal fillers to give greater volume to areas such as the lips and cheeks. It is important for most transgender patients that their appearance looks appropriate for their new gender identity and it’s therefore essential that the individuality of the patient is respected and taken into consideration, as should be standard practice with all patients. It is important to take all the usual considerations into account, to be mindful of their desired outcome and what their existing features are, to offer realistic expectations and to give patients a cooling-off period.

Aftercare

As with the initial consultation, aftercare is paramount in ensuring that the patient feels they have been well-looked after and can discuss any concerns or anxieties they have about their treatment. Essentially the aftercare process would be exactly the same as for a non-transgender patient, but with added emphasis on review to ensure that the patient is happy with the outcome whilst they are getting used to their new identity and appearance.

A growing practice

I believe the treatment of transgender patients is a growing area in medical aesthetics and practitioners should ensure that they educate themselves and their practice teams with the associated complexities of the transitioning process so that they can offer transgender patients a wholly positive and professional experience. Ensuring that you are well read about the subject, attending educational events and shadowing experienced colleagues will all contribute to providing the best possible experience and outcome for your patients. The unique needs of individuals should always be taken into account and a bespoke treatment plan discussed fully with the patient to ensure that any anxiety associated with the transitioning process is kept to a minimum and not exacerbated by their clinical experience. 

References

  1. Gender Identity Research and Education Society, Monitoring Gender Nonconformity – A Quick Guide, (United Kingdom: www.gires.org 2015) <https://www.gires.org.uk/wp-content/uploads/2014/09/Monitoring-Gender-Nonconformity.pdf>
  2. Kate Lyons, Gender identity clinic services under strain as referral rates soar, (United Kingdom: www.theguardian.com 2016) <https://www.theguardian.com/society/2016/jul/10/transgender-clinic-waiting-times-patient-numbers-soar-gender-identity-services>
  3. LGTB Foundation, Transforming Outcomes A review of the needs and assets of the trans community., (www.edf.org.uk, 2017), <http://www.edf.org.uk/wp-content/uploads/2017/09/Transforming-Outcomes.pdf> p.11.
  4. Asscheman H, Gooren LJ, ‘Hormone Treatment in Transsexuals’, 1992, Journal of Psychology & Human Sexuality, 39-54.
  5. Giltay EJ, Gooren LJ (August 2000). “Effects of sex steroid deprivation/administration on hair growth and skin sebum production in transsexual males and females”. Journal of Clinical Endocrinology and Metabolism. 85 (8): 2913–21
  6. Kopera D, Impact of Testosterone on Hair and Skin. Endocrinol Metab Syndr, 2015, 4:187. <https://www.omicsonline.org/open-access/impact-of-testosterone-on-hair-and-skin-2161-1017-1000187.php?aid=59770>
  7. Viviscal Hair Growth Supplement, 2018. <https://www.viviscal.co.uk/clinical-trials-cj>
  8. Ablon Glynis, A Double-blind, Placebo-controlled Study Evaluating the Efficacy of an Oral Supplement in Women with Self-perceived Thinning Hair, J Clin Aesthet Dermatol. 2012 Nov; 5(11): 28–34.
  9. MH Gold, et al., Update on Fractional Laser Technology, J Clin Aesthet Dermatol. 2010 Jan; 3(1): 42–50. <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2921736/>
  10. V Bruce, M Burtin et al., Sex Discrimination: How Do We Tell the Difference between Male and Female Faces?, 1993, Department of Psychology, University of Nottingham. <https://www.ncbi.nlm.nih.gov/pubmed/8474840>

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