Transgender patients and their skin

What does it mean to be transgender?

Transgender people identify with a gender that differs from the sex assigned at birth.

• Sex assigned at birth refers to the male or female (or intersex) designation on their birth certificate based on anatomy, reproductive organs, or chromosomal status [1,2].
• Gender identity refers to the deeply held sense of being a man (boy), woman (girl), or other gender, including no gender. This may not be outwardly visible to others.
• Gender expression refers to the external cues such as name and pronouns used, haircut, clothing, behaviour, and voice or body characteristics that convey gender to others.
• Cisgender is an adjective that refers to people whose gender identity is the same as their sex assigned at birth.
• Transgender is an adjective that refers to people whose gender identity differs from their sex assigned at birth.
  • Transgender women were assigned male sex at birth but identify as female, typically use the pronouns she/her/hers, and have a feminine gender expression.
  • Transgender men were assigned female sex at birth but identify as male, typically use the pronouns he/him/his, and have a masculine gender expression.
• Some people do not identify with the binary male or female gender, and may identify as non-binary, genderqueer, or gender non-conforming. They may use pronouns such as they/them/their, or others.

How can healthcare professionals create an inclusive environment for patients of all genders?

Transgender patients commonly report experiencing discrimination in healthcare settings, difficulty accessing medically necessary health care, and stigma caused by medical staff unfamiliar with transgender-related care. Training of medical staff and dedication to ongoing, consistent inclusivity across a medical system, helps improve patients’ willingness to disclose essential information to get the best care.

• Consistently ask questions about preferred name, preferred pronouns, gender identity, sex assigned at birth, using intake questionnaires when patients first access medical care in your clinic or health system [2–4].
• Address patients by their preferred name, even if it differs from their legal name. Indicate the patient’s preferred name in the electronic health record so all medical staff can call them by the correct name.
• Use patients’ preferred pronouns when appropriate, especially when the patient is not present.
• Provide and display signs for gender neutral restrooms, preferably for only one occupant.
• Use gender non-specific language when addressing patients and asking about their relationships.

Medical staff set the tone for office culture, and their behaviour toward transgender patients can create a welcoming environment from the beginning. Training staff is critical to help make transgender or non-binary patients feel comfortable.

• Medical staff training should be ongoing. Free resources aimed at helping medical staff engage with patients of all genders respectfully are available to assist health professionals. Free, high-quality, online resources are available for help [5,6]. These are best supplemented with respectful physician-led discussions with staff to set the right tone for the clinic.
• Medical staff should be trained to ask sensitive questions in privacy and avoid unnecessary questions out of curiosity. Patients should be offered chaperones based on the medical complaint and extent of the examination.

What are the dermatologic effects of hormonal treatments for gender affirmation?

Androgens for transgender men

Many effects of testosterone begin within one month and reach their peak two years after hormone initiation [7]. Common effects of testosterone on the skin include [8]:

• Increased skin sebum production
• Increased body and facial hair production
• Decreased scalp hair density
• Fat redistribution.

For transgender individuals receiving testosterone, common dermatologic changes include [8]:

• Increased facial and body hair growth
• Increased acne [9]
• Androgenetic alopecia (male pattern hair loss) on the scalp.

Common treatments include:

• Acne: For mild cases, topical retinoids, benzoyl peroxide, and/or antibiotics may be sufficient [8]. For moderate to severe cases that may require potentially teratogenic acne treatments such as isotretinoin, consideration and discussion of reproductive potential is required. Testosterone alone is not considered adequate contraception, as pregnancy has been reported in patients with intact ovaries and uterus receiving testosterone who were amenorrhoeic or oligomenorrhoeic [10,11].
• Androgenetic alopecia (male pattern hair loss): First-line treatment is topical minoxidil. Oral finasteride 1 mg daily may be considered for patients who have achieved desired masculinising effects from testosterone. In a small series of 10 transgender men taking oral finasteride, no significant decrease in serum testosterone and no changes in masculinising effects from testosterone were noted [12].

Oestrogens for transgender women

Most effects of oestrogen occur within the first few months and reach maximum effect after a few years of hormone therapy [7]. Common effects of oestrogen on the skin include:

• Decreased skin sebum production
• Decreased body and facial hair growth
• Increased epidermal thickness
• Increased melanocyte stimulation
• Altered sweat and odour patterns.

For transgender women patients, common dermatologic changes include:

• Reduced facial and body hair growth, though facial hirsutism often remains despite optimised hormonal therapy [13]
• Decreased acne and slowed androgenetic alopecia (pattern hair loss) on scalp [14].

Common dermatologic concerns of this population include [8]:

• Hirsutism and pseudofolliculitis barbae (razor bumps); laser hair removal should be considered.

What are procedural treatments for gender affirmation?

Physical transformation is a critical part of aligning with one’s gender identity for many transgender individuals. For some, they may be satisfied with the effects of hormonal interventions alone. Others may seek to procedurally alter their face and body to help better align their physicality with their identity. Transgender women have shown priority to their faces in this physical transformation, whereas transgender men prioritise their chests, perhaps each reflecting what they feel is the largest barrier to outwardly passing as their identified gender [15]. Importantly, it should never be assumed that an individual wants to do any aspect of physical transitioning, and it should be remembered that many individuals identify somewhere outside of the male/female binary.

Facial affirmation

What are the differences between masculine and feminine faces?

• Masculine faces have wide foreheads with a prominent supraorbital ridge, flat eyebrows, and deep-set eyes. The nose is larger and wider, the cheeks are flatter and broader, and the lips are thinner, than in a feminine face. The jaw creates a squared shape, as does the chin, which is long [16].
• Feminine faces have smooth-appearing foreheads with arched eyebrows and open-appearing eyes. The nose is small and up-turned, the cheeks are full and angled, and the lips are full. The jaw creates a heart shape, with a thin, more pointed chin.

What can be done to masculinise/feminise a face?

• Surgery is the only permanent way to masculinise or feminise the face. Typically performed by a plastic surgeon, most aspects of the face can be reshaped to a patient’s desires [17].
• Botulinum toxin, by controlling muscle contraction, can impact the textural appearance of the forehead, the shapes of the eyebrows, give the eyes a more open appearance, and help contour the jaw.
• Aesthetic fillers, by adding volume, can affect the shape of the eyebrows, nose, cheeks, lips, jaw, and chin.
• Other less-commonly performed procedures can accomplish similar outcomes.

Issues with prior illicit filler use

• The use of fillers occurs at high rates amongst transgender individuals, estimated to be up to 50% in the United States and sometimes higher in other countries, such as 68% in Thailand [18–20].
• Individuals may be injected with non-medical-grade silicone or other atypical materials, including tyre sealant and cement.
• Illicit fillers can lead to medical complications, including granulomas, angioedema, lymphovascular compromise, infection, and death [21].

Chest affirmation

Many transgender men choose to bind their chest with a compression garment, tape, or wrap to create a more flattened appearance. Some proceed to mastectomy to permanently remove the breast tissue. Transgender women may choose to get breast implants. Chest surgical intervention is known as “top surgery.”

What skin consequences to chest binding have been reported?

Skin consequences of chest binding can include:

• Skin breakdown
• Acne
• Miliaria
• Fungal skin infections
• Contact dermatitis [22,23].

What can be done for post-surgical scarring?

• Lasers and light sources can reduce redness and improve texture to surgical scars.
• Keloid and hypertrophic scars can be treated with a variety of techniques, most commonly being an injection of a corticosteroid.

Genital affirmation

Genital surgery is more commonly known as gender affirmation surgery, or “bottom surgery” [24]. Genital surgery for transgender men may or may not be accompanied by hysterectomy and/or oophorectomy.

What procedures are being done for genital reconstruction?

• Vaginoplasty: the creation of a vagina from penile/scrotal or, less commonly, intestinal tissue.
• Phalloplasty: the creation of a penis from donor tissue, often from the forearm, thigh, or abdomen.
• Metoidioplasty: the release of the testosterone-enlarged clitoris to function as a more mobile and potentially erectile penis.

What procedures are needed prior to genital reconstruction?

Both vaginoplasty and phalloplasty often require pre-operative laser hair removal [25]. Without laser hair removal, neovaginal hair growth can lead to obstruction and sequelae including infection. Laser hair removal is done prior to phalloplasty to avoid hair running the full length of the neophallus.

Are there dermatologic issues related to neogenitalia?

• Viral warts and HPV-associated (human papillomavirus) carcinomas have been reported in neovaginas [26,27].
• Inflammatory disease can present, including reported cases of lichen sclerosus and contact dermatitis [28,29].

Other aspects of procedural care for transgender patients

Laser hair removal unrelated to gender confirmation surgery

• Laser hair removal is the #1 reported facial procedure amongst transgender women [15].
• Oestrogen reduces hair on the face and body, but not always to zero [30].

Hair transplant

• Feminine hairlines are lower and more rounded than masculine hairlines [31].
• Hair transplant may be the only option for transgender women who are transitioning after significant androgenic alopecia has begun.
• Transgender men may choose hair transplants for scalp, eyebrow, and beard hair.

Body contouring

• Liposuction and fat-grafting may help redefine someone’s curve.
• Radiofrequency, ultrasound, and cryolipolysis can be added for smaller adjustments.