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Treating and Supporting Transgender Patients in Dermatology

September 17, 2020

2020 Expanded Discussion

Aligning our outer appearance with how we feel on the inside is not only an important factor in feeling self-assured, but in having confidence as we engage with the world.

In 2016, approximately 1 million people in the United States identified as transgender. To varying degrees, transgender people transition their physical appearance to more closely align with their identified gender through social, hormonal and procedural methods with the help of a multidisciplinary team of health care providers, including dermatologists. For transgender patients, non-invasive aesthetic procedures can help support both simple and complex therapy plans by providing an immediate boost to confidence and personal safety by affirming desired gender characteristics.

More and more gender affirming therapies are including treatment from dermatologists and are becoming an integral part of the transitioning journey. Dermatologists’ knowledge of the unique needs of skin, facial contours and natural aging is an imperative piece of a thoughtful therapy plan.

Doris Day, MD of New York, New York spoke about the life-changing role non-invasive physical enhancement can have for transgender patients. She says that transgender and non-binary patients can benefit greatly from non-invasive procedures like strategic use of fillers and hair removal to help affirm their gender identity.

 

How can dermatologists best serve transgender patients?

It comes down to the same things you want to do for all patients:  be respectful, listen and educate.

Given the plethora of challenges faced by transgender patients in the culture at large, it is not surprising that for many years, speaking openly with a physician was difficult for many.  With varying degrees of education on skin in general and in particular the changes induced by hormone therapies, many patients wondered if they even needed a dermatologist or – if they did make an appointment – would a dermatologist be well-equipped to help? Dr. Day posits that, while we want to make visits comfortable for all patients, dermatologists have an extra responsibility to provide a safe, friendly space to help transgender patients navigate their individual experiences.

A study published in the November 2015 Journal of the American Academy of Dermatology found that in a survey of 327 people, most transgender women indicated that the perceived feminine look of their face was the most important piece of their transition. In this light, it becomes even more important to help patients understand that the changes in skin for patients undergoing feminizing hormone therapy are abundant. These can include reduced sebaceous gland activity, slow growing body and facial hair, smoother skin, reduced pigment production and more.  Therefore, even prescribing an appropriate topical skincare regimen is an important element in helping to maintain healthy skin and great confidence. Dr. Day points out,

“When you can see the difference, like when you quit smoking and can see your skin tone is clearer or when you lower your salt intake and can see that your eyes are less puffy – you get the connection to your overall health. The same goes for gender affirming treatments.”

Even undergoing hormone therapies, it can take years to experience the full effects of hormone therapy that may impact facial structure, thus it is recommended transgender patients wait two full years before undergoing facial surgeries. This, Dr. Day says, is one of the reasons more patients are now turning to their dermatologist in the meantime for gender-affirming treatments – they can immediately experience some of the changes they are seeking. Dermatologists can play a crucial role in giving the face a more feminine contour with dermal fillers in the cheeks, chin, lips and even along the side to nose and a smoother texture with treatments such as laser hair removal.

Additionally, Day would remind us that that many patients don’t plan to transition fully, due to cost, risk of surgery, emotional impact and other health reasons, making non-invasive facial changes all the more important.

 

Is the consultation unique in the transitioning process?

While patients may have some hesitation in engaging in a new relationship, many physicians, too, may have concerns about approaching the treatment of patients undergoing hormone therapy. Starting with something as fundamental as using the patient’s preferred pronoun is a great place to start.

Physicians should also get in the habit of asking their transitioning patients many questions before starting treatment while still respecting their limits of comfort in discussing their transition. Be cognizant that some of the information physicians have access to, including medications or hormone therapies that may show up on blood tests, may be sensitive to the patient.

Listening to the patient thoughtfully and carefully is critical, throughout the process. It’s essential to remember that there is fluidity when it comes to gender identity and physicians should be careful not to insert a binary view of “masculine” or “feminine”. Let patients lead the way. Dr. Day shares that she often has to defer.

“I always feel like I can do more to help feminize the patient, but realize there is no need. Just a few changes can be enough for the patient and we need to learn to follow their lead. We need to learn to actually see people more clearly, because we have an important role in this.”

To reach out to the transgender community, dermatologists may consider sharing consenting patient testimonials on their website along with before and after photos of their transgender patients. Not only does this help transgender patients gauge what to expect from treatments but also helps them to feel more comfortable to schedule an appointment with you.

The process of grounding oneself in one’s identity is tricky under the easiest of circumstances.  Remember that with any patient, slowing down, being present and listening will go a long way toward patient-satisfaction and better outcomes. However, care and respect carry even more weight for those who may be additionally vulnerable.

 

Are you seeing and treating more transgender patients?  We’d love to hear how you are supporting their journey in the comments below.

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