Transforming Skin: Transgender Dermatology

For the transgender individual whose misrepresentative outer appearance is at the root of their personal conflict, it may be clear how the skin is a critical component of establishing self-harmony. However, the role of the dermatologist in their care is yet to be determined.
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For the transgender individual whose misrepresentative outer appearance is at the root of their personal conflict, it may be clear how the skin is a critical component of establishing self-harmony. However, the role of the dermatologist in their care is yet to be determined in the academic literature and subsequently in routine practice, but to me it has always been evident that we dermatologists have a unique perspective on addressing their needs in both a medical and aesthetic manner.

Physical transformation often begins with hormonal intervention, which, if done early enough, can interfere with puberty and help guide natural contouring into the desired gender. Studies of hormone use in transgender individuals show potential skin-related side effects, with testosterone creating an oilier canvas, and estrogens leading to dryness and body hair loss. A transgender man may in turn experience worsened acne, while, conversely, a transgender woman may develop eczema and itch. Fortunately, acne and eczema are two of the most common complaints in any dermatologist's office, so both are readily managed successfully. In addition, while testosterone causes the growth of often-desired additional hair for transgender men, estrogen-induced facial and body hair loss is often insufficient for transgender women. Thankfully, the use of lasers for hair removal has advanced, with nearly permanent epilation achieved in as few as four to six treatments. The emotional burden of being a transgender woman needing to shave her beard may be easily eliminated in less than half a year.

Surgical procedures are currently the primary methods for body transformation, but many dermatologists offer noninvasive body contouring options for fat and cellulite reduction, which in turn may create a more feminine figure. Breast and genital reconstruction continue to be an impressive and effective way of altering one's physicality and will likely remain in the hands of experienced plastic and urologic surgeons, but post-operative scarring can be managed by dermatologists with injections and lasers to reduce or eliminate redness while resurfacing the skin to approximate its original texture.

Even though one's genitalia may be new after surgery, it may still be a site of common skin conditions. As these surgeries become more common, dermatologists and gynecologists are slowly learning to navigate the new topography. Many skin diseases have been reported in the vaginas of transgender women, including both skin and gastrointestinal cancers, depending on the tissue of origin. The management of these conditions is imperative, and the fact that they can occur cannot be ignored; therefore, a mutual understanding between patient and physician must be established. Both parties must recognize each other's comfort level and ultimate intentions.

As for the face, invasive surgery is the most widely used technique to reshape one's facial structure into its proper gender. However, many people avoid such procedures because of cost, stigma, lack of access, or the fear or medical contraindication of undergoing surgery or general anesthesia. There is now a role for dermatologists to help reestablish facial contours in a safer, noninvasive, and non-permanent fashion. This could serve to bridge the gap while awaiting definitive surgery, as an adjunct following surgery, or as an alternative altogether. Through injections alone, the features of one's face can be manipulated to create a more masculine or feminine appearance. For example, a neurotoxin such as Botox can help a transgender woman have an apparently flatter forehead, with more opened eyes and a peaked eyebrow, while fillers could be used to accentuate her cheekbones, lips and chin. These procedures occur in the office, often without any anesthesia, and require little to no recovery time.

Unfortunately, many individuals have relied on nonprofessionals for their procedures, incurring devastating consequences ranging from nodules and swelling to infections and death. Pumping parties, non-licensed practitioners and overseas clinicians have led to the injection of non-medical-grade silicone and even household glues and cements, all for a lower cost, but with the serious and often irreversible outcomes mentioned above. Dermatologists are becoming increasingly aware of these complications and often serve as a primary source for their management.

It is not yet commonplace for dermatologists to be sought after in the care of transgender individuals. I hope to bring dermatology to the forefront of transgender care, making our resources known to the community, while making the dermatology community aware of how to better utilize these resources for a new good. Through public voice and dedicated research, I plan to expand the practice of transgender dermatology, directing it toward the increasingly better-understood needs of our patients and applying and adjusting commonly used techniques for a novel purpose. With improvement in our abilities, expanded access to care, and a widely acknowledged understanding of what we as dermatologists have in our armamentarium, I hope to serve the greater community by providing an effective and safe option for realizing one's self-image and caring for it thereafter.

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