Dermatologists Play a Key Role in the Transformation of Transgender Patients

Doug Brunk

September 25, 2020

Whether they realize it or not, dermatologists play a key role in the physical transformation of transgender patients, according to Doris Day, MD.

While clinical management of this patient population has historically been limited to experts in mental health, endocrinology, and select surgeons with experience in sex reassignment surgery, "what dermatologists provide on an aesthetic level through noninvasive or minimally invasive procedures can have a big impact in helping that transformation," Dr. Day, of the department of dermatology at New York University Langone Health, said during the virtual annual Masters of Aesthetics Symposium.

Dr Doris Day

"But, we have to go through a transformation of sorts as well as we care for these patients, because we need to help them in the way that best matches their needs. We need to know about their mental health and the medicines they're taking as well as their goals for their outcomes. If they're working with surgeons for sex reassignment, we should have discussions with those clinicians as well."

Gender-affirming hormone therapy is the primary medical intervention sought by transgender people, she said. This allows the acquisition of secondary sex characteristics more aligned with their gender identity. Feminizing hormone therapy affects the skin by reducing sebaceous gland activity, "which can lead to fewer acne breakouts and smaller pores but also cause drier skin," Dr. Day said. "We can slow down the growth of body and facial hair and we can perform hair removal treatments. We see decreased male-pattern scalp hair loss, and we see smoother skin as the fat under the skin becomes thicker and the pores become smaller. We can also have increased pigment production, which is always a good thing."

In a 2016 survey of 327 transgender individuals led by Dr. Day's mentee, Brian A. Ginsberg, MD, and published in the Journal of the American Academy of Dermatology, most transgender women indicated that their face was most important to have changed, while for men it was the chest. Hair removal was the most common women's facial procedure, followed by surgery then injectables, mostly performed by plastic surgeons.

Limitations of hormone therapy include the fact that it can take 2 or more years for associated changes to fully develop. "At least here in New York, patients want everything in a New York minute, so that's always an issue," she said. "We often recommend that patients wait at least 2 years after beginning hormone therapy before considering drastic feminization surgeries, but there are many options we have for them while they're waiting for that. Even with hormone therapy, the bone structure of the face is unaffected, so we need to be artistic in creating a more feminized balance in order to help them physically match their gender to their identity."

Noninvasive aesthetic procedures can compound the effects of hormone therapy, in addition to offering physical transformation beyond hormone therapy. She recalled assisting one of her patients transform from male to female. Over a period of 2 years, Dr. Day added Botox then Juvederm Voluma to the patient's cheeks and chin, "and she started her transformation to a more feminized gender matching identity," she said. Next came a hair transplant and the injection of more Voluma and fillers in the lips and cheeks on an as-needed basis.

"During one visit, I felt that we could still do more," Dr. Day recalled. "She looked at me and said, 'Actually, I feel so happy. This looks like me as I imagined I would look in my mind.' I realized that my vision for her wasn't the same as her vision for herself. She was thrilled with her transformation.

"I realized that as we see these patients, for all we learn about the science of gender transformation, the emotional aspects of our vision of what we can accomplish for our patients versus their vision of what their happiness level is may not entirely match. We have to be careful to help them celebrate their version of their femininity or masculinity, rather than trying to have our patients match what we think we can accomplish for them with our own sense of what femininity or masculinity is."

Over time, Dr. Day said, the patient's acne scars improved with fillers and microneedling treatments, and with the hormone therapy. "As we softened her appearance and as she made changes like the earrings that she wore and the hair style that she chose, she was in line with what her perception of her femininity was," she said. "Little by little we've been watching her grow into her new self. It's been a beautiful transformation. I was honored to be able to share in that journey with her."

Dr. Day reported having no relevant financial disclosures.

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