11 Aesthetic Concerns in Transgender Patients

Yunyoung C. Chang and Jennifer L. MacGregor

Summary

Transgender and nonbinary gender patients are an important population of consideration in male aesthetic dermatology. Although the reported prevalence and visibility of the transgender population has risen over the past decade, those who transition continue to encounter obstacles when it comes to receiving medical and cosmetic care by trained providers. Barriers to access include limited outreach, unfamiliarity of the patient on available procedures, insufficient numbers of trained providers, lack of psychosocial and community support, high costs, and delays while undergoing psychological evaluations. Dermatologists may play a central role in the aesthetic care of the transgender patient, by improving outreach, increasing patient education, adopting more inclusive office procedures, allowing quicker access to transitioning procedures, and offering safe, minimally invasive, and less time-consuming aesthetic treatments. It is important to note that transgender aesthetic preferences may not follow the traditional binary ideals of beauty, including “masculine versus feminine,” and should be tailored as per individual patients. Although the impact of minimally invasive dermatologic procedures may be more modest than surgical treatments, dermatologic enhancements can help align appearance with a patient’s gender identity, improve self-confidence, and, ultimately, improve the quality of life in the transgender population. This chapter will review the process of gender transition, available minimally invasive procedures for the face and body, and illustrative case examples.

The prevalence of the transgender population has shown an upward trend, with study estimates reporting double the prevalence rates compared to a decade ago.1,2 One recent study reported about 0.6% of adults, approximately 1.4 million, and 0.7% of youth aged 13 to 17 years, or approximately 150,000 youth, identify as transgender in the United States.¹ With the growth in the transgender population, medical providers including dermatologists must strive to improve their overall understanding, awareness, and knowledge in the medical care for this population.

11.2 Gender Transitioning

11.2.1 Overview: Medications and Surgical Procedures for Gender Transition

Gender transitioning refers to a process of aligning one’s gender presentation with one’s internal gender identity. Gender transitioning can occur on multiple levels, including social transitions, medical treatments, and/or surgical transformations.³ Social transitions involve using a preferred name and pronouns, and some may legally change their name.

The use of cross-sex hormone therapy for medical reassignment has become more commonplace in the transgender population.⁴ Transgender males (biologically female transitioning to male) may choose to undergo hormonal therapy with exogenous testosterone,⁴ which suppresses female secondary sex characteristics and masculinizes transgender men. The physical changes can begin within 3 months of initiating therapy, including medically induced menopause, changes in the distribution of fat on the face and body, enhanced muscle mass, and increased libido. Later changes include increased clitoral size, vaginal skin atrophy, and a deepened voice.⁴ Skin changes that occur with testosterone therapy include increased facial and body hair, increased oil production and acne, and male pattern hair loss.⁴ Nonbinary individuals may also choose to undergo medical therapy, by balancing hormones based on their personal goals.

For transgender females (biologically male transitioning to female), hormonal therapy includes hormonal supplementation with estrogen, with or without anti-androgen therapies like spironolactone or cyproterone acetate.⁴ The goal of therapy is to induce female secondary sex characteristics, including breast formation, fat redistribution, muscle mass reduction, testicular size decrease, and female patterned hair growth.^4,5 The skin can become drier and thinner, with less oil production and smaller pore size. The rate at which these desired physical changes occur after hormonal therapy initiation varies, ranging from within a few months to 2 to 3 years.⁵ This rate will also depend on other factors, like genetics and age at which you start therapy. Although medical therapy alone may lead to significant visible changes (Fig. 11.1), some patients desire faster, more immediate, and more striking physical changes. Minimally invasive aesthetic treatments, which will be discussed in detail later, can be used to further enhance the desired feminine appearance by softening and balancing features, contouring the face and body, and providing more immediate results (Fig. 11.2, Fig. 11.3, Fig. 11.4, Fig. 11.5, Fig. 11.6, Fig. 11.7).

Surgical gender reassignment procedures are also available for transgender patients in addition to medical therapy.5 Based on guidelines set by the World Professional Association for Transgender Health (WPATH) and the Endocrine Society, transgender patients should have undergone 1 year of hormonal therapy and living as the desired gender prior to gender reassignment surgeries.⁴ For transgender males, surgical options include oophorectomy, hysterectomy, scrotoplasty, phalloplasty, metoidioplasty, and chest masculinization surgery.⁶ Procedures available for transgender females include removal of the testes (orchiectomy), creating a neovagina (vaginoplasty), breast augmentation surgery, tracheal shave to soften the “Adam’s apple” (chondrolaryngoplasty), and voice feminization surgery. Facial plastic surgery is commonly pursued to soften facial contours, including rhinoplasty, fat transfer, forehead and chin implants, brow lift and forehead lift surgery, and orthognathic surgery.⁵ A population study published by Boston Medical Center between 2004 and 2015 reported 35% subjects had undergone at least one gender-affirming surgery, suggesting that the majority of transgender patients do not undergo any type of gender-affirmation surgery.⁷ This low rate may be due to multiple reasons, including paucity of providers, high financial cost, lack of interest, or aversion to invasive procedures.

11.2.2 Quality of Life Relating to Gender Identity and Aesthetic Procedures

Research has shown that transgender individuals report a low quality of life (QOL) and high incidence of mental health issues. In effect, medical and surgical gender-affirming surgeries are associated with higher QOL and high patient satisfaction.8,9 Despite this, even after transitioning, the transgender population continues to be at risk of lower QOL and mental health issues than the general population.¹⁰ Cosmetic concerns are especially tied to the emotional well-being of transgender patients because, by definition, their perceived gender identity and desired aesthetic presentation to the world differ from their biological sex. Improving the cosmetic appearance of transgender individuals based on their individual aesthetics may, in turn, further improve their QOL.

11.2.3 Barriers to Care

In order to improve access to medical care, providers must consider the many barriers transgender individuals face as they navigate the transition process. Barriers to good medical care include patients’ unfamiliarity with available procedures, paucity of trained providers in transgender health, delays while undergoing psychological evaluations, and high costs associated with required medications and surgical procedures. Additionally, distant location from metropolitan areas or large medical centers and lack of family or social support make access difficult for many patients. Medical providers may also become a barrier to good care. Physicians have the power to make themselves available or unavailable to transgender patients, provide transgender-friendly or transgender-unfriendly office environment, and to provide or delay prescriptions and cosmetic treatments at a pace that may not fit with the patient’s desired timeline. Board-certified providers may charge more money for procedures, and lack of insurance coverage for cosmetic procedures may be cost prohibitive for those patients without available resources. Confronted with societal pressures to conform to a binary gender system and ideals of beauty while faced with these barriers to receiving treatment, transgender patients may experience worsening anxiety, depression, and despair. Given these barriers, some patients pursue medical and aesthetic care beyond traditional medical providers,¹¹ and may turn to illegal products, international internet prescriptions, or unlicensed or untrained providers. Unfortunately, cases of transgender patients resorting to “pumping,” or using liquid silicone, or receiving care from secondary providers have been reported,^12,13 with associated complications. In contrast, it is optimal to receive aesthetic care from board-certified, trained medical physicians with experience in these procedures and dealing with the possible complications.

In addition to medical and surgical treatment options, all transgender patients may benefit from adjunct minimally invasive aesthetic procedures provided by dermatologists and other board-certified physicians. Minimally invasive aesthetic procedures may be more immediately available, provide results in a relatively short period of time with minimal downtime, and improve ultimate outcome during the transition process, thereby bridging the gap in receiving medical care and achieving desired aesthetic goals. Minimally invasive procedures are especially important for patients prior to and during the first year of hormonal/medical therapy while patients await physical changes and/or gender affirmation surgery. More immediately available procedures may help ease gender dysphoria, further increase self-esteem, and improve satisfaction with appearance and QOL.

Dermatologists can address specific cosmetic concerns including gender-affirming facial and body-contouring, hormone-related skin changes, and surgery-related scarring.14,15 Injectables, like botulinum toxin injections and filler treatments, are performed in an outpatient medical setting with minimal risk and little downtime compared to surgical interventions. Facial injectables can be started immediately to enhance or diminish certain features and to masculinize or feminize features according to patients’ aesthetic goals. Laser treatments and body-contouring devices are also available immediately and have high safety standards when performed by trained providers. With these noninvasive procedures, there is minimal need for psychologic vetting, medical pretreatment, or other delays that are routinely required prior to hormonal therapy and invasive surgery. They may also be more cost-effective for patients with more limited resources. In cisgender patients, minimally invasive aesthetic procedures have been shown to improve body image and QOL.¹⁶

Despite the growing medical literature regarding hormonal therapy and surgical procedures for gender transitioning, educational resources and published data regarding minimally invasive aesthetic procedures for transgender patients are sparse. Recently published reviews outline current dermatologic literature to instigate thought around this topic, but more detailed procedural outlines, case series, and larger studies on how dermatologists can contribute to the cosmetic transformation of the transgender patient would be helpful for the dermatologic community.^{14,15,17,18,19} Studies are currently underway to assess QOL data in transgender individuals who have received minimally invasive aesthetic services. Growing literature may cultivate an increased number of providers qualified and comfortable in performing aesthetic treatments in this population, thereby increasing access and QOL, as well as aid in future counseling efforts. The remainder of this chapter will review the role of medical providers, detail available minimally invasive cosmetic procedures relating specifically to the transgender population, and exhibit with our case examples.

11.3.2 Role of Dermatologists and Other Medical Providers

Dermatologists and other medical care providers should keep an open mind when assessing transgender patients for aesthetic procedures, as goals may be to feminize, masculinize, both, or neither. Transgender individuals’ aesthetic goals may diverge from the traditional gender paradigm of “masculine” or “feminine” ideals of beauty (Table 11.1).^19,20,21 Accordingly, we advocate for a more flexible assessment of transgender patients. Practitioners should inquire about a patient’s individual goals during the initial consultation and throughout follow-up visits, listen to all patients, and discuss openly about their preferences, prior to proceeding with recommendations and treatments. As mentioned earlier, mental health issues remain a big issue in the transgender population. If any symptoms of mood changes or depression are detected, dermatologists should ensure that patients have a working relationship with a psychiatrist as well as strong social support.

Table 11.1 Traditionally “masculine” versus “feminine” facial features

As with all patients, the patient–physician relationship is important when dealing with transgender patients. Medical providers should avoid patronizing language regarding the patient’s decisions, listen deliberately, and develop an individualized plan to help moving forward with the transition process. The office medical forms should be comprehensive of all gender orientations, and clinical staff should also be trained to inquire and address patients with their preferred pronouns and names. With supportive care and better outreach, dermatologists can bring more transgender patients into the care of board-certified and trained physicians.

11.3.3 Patient Preferences

A recent cross-sectional survey study of 327 people showed that a majority of transgender men reported prioritizing their face as the most essential body part to have changed, over the face or genitals.¹⁴ These patients stated that they were mostly concerned about cosmetic procedures “looking good,” more so than the risk of scars, complications, or other risks. In contrast, transgender women reported their face as the most essential body part to have changed. Of facial procedures, transgender women stated hair removal was the most preferred cosmetic treatment, followed by surgery and then injectables.¹⁴ Transgender women reported seeking procedures mostly from plastic surgeons,¹⁴ which may be due to patient preference, prior physician relationship, better outreach, or ease of access.

Clinical Pearl: Transgender men and women may have different priorities when it comes to cosmetic and aesthetic treatments, with a majority of transgender men focusing more on the chest and transgender women focusing more on the face based on one study. It is important to ask about individual patient preferences when performing initial consultations.

Transgender men benefit from dermatologic care and minimally invasive aesthetic treatments, and more awareness on available procedures is needed in the general public. As stated previously, transgender men report that their primary aesthetic concern is their chest, rather than their face or genitals. In our experience, pseudogynecomastia (residual breast tissue) posthormonal therapy with exogenous testosterone does not respond well to minimally invasive treatments like cryolipolysis (Fig. 11.8), and we routinely refer these patients for surgical correction. Noninvasive body contouring, like cryolipolysis and pulsed focused ultrasound, of other body areas, particularly in the abdomen, flanks, and submental regions, may be sought after and remains a good treatment option in transgender men.

Related posts:

Aesthetic Concerns in Skin of Color Patients The Male Aesthetic Patient: Preferences and Practice Keg to Six Pack: Fat and Cellulite Treatments Taking a Hard Look: Soft Tissue Augmentation Finding the Right Balance: Chemical Peels Tincture of Time: Facial Aging and Anatomical Considerations

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