Caring for our Transgender Patients

 

Caring for our Transgender Patients
Susan Massick, MD


As dermatologists, we should strive to create an inclusive environment for patients regardless of race, gender, sexual orientation, or ethnicity. While progress has been made in embracing diversity and advocating for equity and inclusion, changing political landscapes and partisan politics may negatively impact access to care for underserved and vulnerable groups. Currently over 1.3 million Americans adults (0.5%) and 300,000 adolescents ages 13-17 (approximately 1.4% of the youth population) identify as transgender.¹

People who are receiving gender-affirming care may seek our dermatologic expertise to manage physiologic changes that will occur with hormonal therapy. The National Center for Transgender Equality just completed its largest transgender survey in December 2022 with results to be released in fall 2023. Based on 2015 data, however, the NCTE found that

• “One-third (33%) of those who saw a health care provider…reported having at least one negative experience related to being transgender, with higher rates for people of color and people with disabilities. This included being refused treatment, verbally harassed, or physically or sexually assaulted, or having to teach the provider about transgender people in order to get appropriate care."²
• “23% of respondents did not see a doctor when they needed to because of fear of being mistreated as a transgender person."²
• “33% did not see a doctor when needed because they could not afford it.”²

Terms and Definitions
It is important for dermatologists and their staff to educate themselves and be familiar with appropriate terminology and definitions in the context of gender diversity and in creating an inclusive patient care environment.

• Gender identity: “a person’s…internal, intrinsic sense of their own gender.”
• Sex: “sex assigned at birth…person’s status as male, female, or intersex based on physical characteristics…and appearance of external genitalia.”³
• Intersex: “people born with sex or reproductive characteristics that do not fit binary definitions of female or male.”³
• Sexual orientation: “person’s sexual identity, attractions, and behaviors. Sexual orientation and gender identity are distinct terms.”³
• Gender expression: “outward manner in which an individual expresses or displays their gender. This may include choices in clothing and hairstyle, or speech and mannerisms. Gender identity and gender expression may differ.”⁴
• Transgender/Trans: umbrella term for “a person whose gender identity differs from the sex that was assigned at birth.”⁴
  
• Transgender Man: person “with a male gender identity and female birth assigned sex.”⁴
  
• Transgender Woman: person “with a female gender identity and male birth assigned sex.”⁴ 
  
• Gender diverse: “people with gender identities and/or expressions that are different from social and cultural expectations attributed to their sex assigned at birth… could include nonbinary… gender nonconforming, and others who do not identify as cisgender.”³
  
• Cisgender: “people whose current gender identity corresponds to the sex they were assigned at birth.”³
• Gender binary: “idea that there are two and only two genders, men and women; the expectation that everyone must be one or the other.”³
  
• Nonbinary: “gender identities outside the gender binary…or as not having a gender at all.”³ 
  
• Transition: “process whereby people usually change from… sex at birth to another gender expression that better matches their gender identity.”³
• Gender affirmation: “being recognized or affirmed in a person’s gender identity. Term in lieu of transition.”³
• Gender-affirmation surgery: “surgery to change primary and/or secondary sex characteristics to affirm a person’s gender identity.”³

It is important to understand that gender identity, sex, and sexual orientation are three distinct concepts. For example, a transgender male was born female, identifies with the male gender but his sexual orientation depends on his sexual identity and attraction. For patients seeking care in your clinic, ensuring a positive experience from the get-go is critical.

Tips to creating an inclusive environment and gender-affirming care in your clients⁵:

1. Annual physician and staff training in cultural awareness and implicit bias
2. Gender neutral terms for intake forms. Make note within electronic medical records and when addressing patients to use gender-neutral language as well as preferred names, preferred pronouns, gender identity along with their legal names and sex assigned at birth
3. Gender-neutral bathrooms, single-occupancy if available

Hormonal Therapy
There are common physiologic changes related to gender-affirming hormonal therapy, typically seen within the first six months of treatment.⁶ The resulting dermatologic effects may affect certain patients more significantly.

Effects of feminizing hormone therapy/Estrogen and anti-androgen therapy for transgender females6:

• Decrease sebum production
• Decrease facial and body hair
• Increase in epidermal thickness
• Increase melanocyte stimulation
• Change in eccrine/apocrine gland production

Effects of masculinizing hormone therapy/androgens for transgender males6:

• Increased sebum production
• Increase in facial and body hair
• Decrease in scalp hair
• Redistribution of body fat

Common Dermatologic Conditions in Transgender Patients
Hormonal therapy will induce the dermatologic side effects that would be expected with testosterone or estrogen hormones.

For transgender males, acne and male pattern hair loss are frequent challenges that warrant treatment if desired and based on severity.

1. Acne: Treat with conventional topical retinoids +/- benzoyl peroxide and topical antibiotics with addition of short course oral antibiotics if needed. If severe enough to warrant isotretinoin, iPledge will still require two forms of contraception and monthly pregnancy testing for any patient with child-bearing potential.⁶
   Typically acne develops and peaks within 4-6 months of hormone therapy and improve after 2 years.⁷
2. Male Pattern Hair Loss/Androgenic Alopecia: While multiple contributing factors increase risk for androgenic alopecia, transgender males will develop in the same pattern as cisgender males. Starting topical minoxidil may help combat hair loss and would be an important therapeutic option to introduce early on. The limited data on the use of oral 5 alpha-reductase inhibitors in transmasculine population points to its safety and potential regrowth of hair but may affect secondary gender characteristics. Current recommendations are to consider use only in a small subset of patients and after at least 1-2 years of testosterone therapy.⁶

Common dermatologic conditions that transgender females experience include:

1. Persistent hirsutism/facial hair: Facial hair growth can persist despite estrogen and antiandrogen therapy and should be addressed with your transfeminine patients. If temporary measures such as typical shaving and compounded eflornithine (Allergan’s Vaniqa has been discontinued) are not effective, proceed to more longterm treatment option of laser hair removal and electrolysis.⁶
2. Pseudofolliculitis barbae: Recommend shaving techniques as you would for any PFB patient with the addition of benzoyl peroxide +/- topical clindamycin to help with inflammation.⁶
3. Melasma: Sun protection and consideration for topical hydroquinone with higher strengths of hydroquinone if needed as well as cosmetic laser or chemical peel options.⁶

Transgender patients may seek your expertise for dermatologic conditions related to their gender-affirming care. We should strive to maintain an inclusive, safe, and welcoming environment where any patient we serve will feel comfortable, respected, and supported.

References 

1. Herman J.L., Flores A.R., and O’Neill K.K. (2022). How Many Adults and Youth Identify as Transgender in the United States? The Williams Institute, UCLA School of Law. williamsinstitute.law.ucla.edu/publications/trans-adults-united-states, Accessed February 12, 2023.

2. James S. E., et al. (2016). Executive Summary of the Report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality, p. 5. www.transequality.org/sites/default/files/docs/usts/USTS-Full-Report-Dec17.pdf. Accessed February 5, 2023.

3. Coleman E et al. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. Int J Transgend Health. 2022 Sep 6;23(Suppl 1):S1-S259

4. Deutsch, M. B. (2016a). Guidelines for the primary and gender-affirming care of transgender and gender nonbinary people (2nd ed.). UCSF. https://transcare.ucsf.edu/guidelines. Accessed February 12, 2023. 

5. Braun, et al. Transgender patients and their skin. www. dermnetnz.org/topics/transgender-patients-and-their-skin. October 2020. Accessed February 5, 2023.

6. Yeung H, Kahn B, Ly BC, Tangpricha V. Dermatologic conditions in transgender populations. Endocrinol Metab Clin North Am. 2019;48(2):429–40. doi:10.1016/j.ecl.2019.01.005.

7. Wierckx K, et al. Short- and long-term clinical skin effects of testosterone treatment in trans men. J Sex Med 2014: 11(1): 222-9.