Dermatology for transgender and gender diverse patients

Dermatologists play a crucial role in providing supportive and inclusive care to a cohort that experiences significant health disparities.

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Australian researchers have teamed up to publish a paper on dermatological considerations for transgender and gender diverse patients.

Lead author and Sydney dermatologist, Associate Professor Deshan Sebaratnam, told The Medical Republic their literature review was designed to provide an Australian perspective for clinicians. The review was published in the latest Australasian Journal of Dermatology.

“It was a bit of a black hole in my knowledge,” he said.

“Even when I went through medical school no one really talked about transitioning or any of that stuff. And then I started to see a few patients and I wanted to learn more.

“There were lots of things which I hadn’t learned in medical school, and I imagined there would be a lot of other people, including those much older than me, who would also be in the same situation. I thought it would be helpful to put in the Australian perspective as well.

“This is a group of patients who experience significant health disparities so anything we can do to help address that is a step forward.”

The University of NSW professor who is based at the Liverpool Hospital Department of Dermatology, was joined for the study by colleague Yaron Gu, and endocrinologist Associate Professor Ada Cheung, both part of the University of Melbourne’s Trans Health Research Group and the Austin Health Department of Endocrinology.

In the multi-disciplinary management of transgender and gender diverse (TGD) individuals, dermatologists could play an important role in managing skin and hair-related issues which contribute to gender affirmation and to the cutaneous sequelae of gender-affirming hormone therapy, he said.

Professor Cheung said dermatological considerations should not be underestimated in TGD patients.

“I think hair and skin is a really big part of people’s gender expression,” she told TMR.

“They are certainly things that when people are undergoing gender transition, they often want to change. And they also want to change because they want to change the way they express their gender and changing their hair and their skin is really affirming.”

She said it was also important to consider that hormone therapies could impact patients’ hair and their skin in a way that they desire and also in a way that they may not desire.

“This can include hair loss or acne,” said Professor Cheung.

“For example, some trans men who are having testosterone or non-binary people who want testosterone may like male pattern baldness, but for others it may make them very uncomfortable – so there’s quite diverse responses.”

This highlights the importance of individualised patient-centred care, she said.

“I think we need to listen, and we need to provide care that’s tailored to individual needs but that’s what we should be doing with all patients ideally,” she said.

The Australasian Journal of Dermatology article also supported the significant part that hair and skin played in gender expression and looks at the general status of gender-affirming care in Australia.

“Several Australian guidelines exist to inform clinicians about gender-affirming care,” the authors wrote.

“Specific detail outlining the process of gender-affirming care in Australia can be found in the Australian standards of care for TGD children and adolescents, the Australian position statement on the hormonal management of adult TGD individuals, and the Australian informed consent standards of care for gender-affirming hormone therapy.

“Gender-affirming care often involves a multidisciplinary team to assess an individual’s gender incongruence and support them through social, medical and legal affirmation pathways (if desired) with psychological and peer support. The provision of gender-affirming care can be lifesaving for TGD people.”

Social transition typically involves the disclosure of one’s gender identity to others, changes in gender expression and changes in names or pronouns. Some may subsequently pursue medical intervention through hormonal or surgical management. Other specific supports available for TGD individuals include vocal training, psychological care and fertility counselling for patients commencing gender-affirming hormones (GAH).

“It should be noted that pathways to affirm gender are individual, and not everyone will desire social, legal, medical or surgical interventions,” the authors wrote.

The authors say dermatologists require appropriate awareness to provide supportive and transparent care to TGD people.

“It has been demonstrated within the Australian literature that poor experiences with healthcare environments are correlated to poorer mental health outcomes for TGD individuals,” they wrote.

“As with cisgender patients, TGD patients require accessible health care that provides autonomy, confidentiality and patient safety in a non-judgemental manner.

“Open-mindedness and knowledge about TGD health concerns are qualities that TGD patients value in healthcare providers. While symbolic gestures such as stickers, flags or brochures may broadcast a culturally safe environment, provider professionalism, knowledgeability, confidentiality and sensitivity supersede such displays.

“When relevant to medical care, asking patients about their gender identity, pronouns and sexual behaviours can demonstrate inclusiveness and quash implicit bias of heterosexuality or cisgender being the norm.

“A prefacing statement such as ‘Our clinic is an inclusive and safe space for all our patients. We routinely ask all our patients this’, may help normalise these questions.”

Diversity should be reflected in patient intake forms, electronic medical records and documentation, and using an individual’s preferred name and pronouns is essential towards developing therapeutic rapport with TGD patients, the author said.

“Confirmation of pronouns and gender identity at each consult may demonstrate cultural understanding for patients who are still exploring their gender identity or identify as gender fluid,” the authors wrote.

“For younger patients, confidential time without parents may be required to allow for open discussions of gender identity, sexuality and practices when relevant to medical care. For clinically indicated examinations, the Australian Professional Association for Trans Health (AusPATH) guidelines recommend a trauma-informed approach. Additional attention should be provided to sensitivity, transparency, consent and acknowledgement of cultural and historical gender issues.”

Acne vulgaris is one of the main issues with testosterone therapy, and while its management in TGD individuals largely follows established guidelines for all patients, there are other considerations, including one of particular importance to patients receiving masculinising GAH – that androgens are well known to affect sebum production in the pilosebaceous unit.

The authors looked at a retrospective comparative cohort study of 46,507 TGD and cisgender adults that demonstrated the incidence of acne in TGD patients receiving masculinising GAH was 2.4 times higher than in cisgender women and 4.1 times higher than in cisgender men.

A retrospective cohort of 988 transgender adults also found that the prevalence of acne increased from 6.3% to 31.1% following the initiation of masculinising GAH. The rate of diagnosis peaked in the first 6 months of initiation, highlighting the necessity of early dermatological intervention.

“Transmasculine individuals may perform chest binding to relieve gender dysphoria but may result in acne as well as other cutaneous adverse effects including pain, pruritis, infection, miliaria, contact dermatitis and scarring,” the authors wrote.

While the management of acne in TGD individuals largely reflects existing guidelines for cisgender patients, they summarised therapeutic considerations unique to TGD patients including:

• For mild to moderate acne, treatments may include benzoyl peroxide, topical retinoids or topical/oral antibiotics.
• More frequent liver monitoring has been suggested in patients commencing tetracyclines alongside testosterone therapy due to the theoretical risk of hepatotoxicity.
• Oestrogen levels in combined oral contraceptive pills (COCs) do not prevent masculinisation and can be safely used alongside testosterone therapy in TGD individuals. The continuous use of COC typically provides menstrual suppression which may relieve dysphoria in transmasculine individuals.

The authors noted that patients should be counselled on the risks and benefits of using COCs for either acne treatment and/or contraception. For individuals with the potential for pregnancy, COCs may be particularly useful if they were being considered for retinoid therapy.

Isotretinoin may be safely initiated in patients receiving GAH without modifications to standard monitoring, however the authors noted that as testosterone was not an effective form of contraception, so patients required ongoing monitoring for pregnancy.

While the association between isotretinoin and adverse mental health outcomes including suicidal ideation remained controversial, the authors said the cumulative mental health impacts of severe acne and being a gender minority warranted closer surveillance in TGD people.

“As such, dermatologists should liaise with an individual’s psychiatrist for a proper mental health assessment prior to initiation of isotretinoin,” they said.

When it came to hair in patients undergoing testosterone therapy, it was important to consider that hair was “an essential aspect of gender expression, and the impacts of hair loss may be particularly profound for TGD individuals.”

Androgens may induce growth in the beard, axillae and pubis as well as increase rates of androgenetic alopecia (AGA), a common disorder of hair loss that affects up to 80% of cisgender males by the age of 80.

“Masculinising GAH therapy may increase facial and body hair growth but may induce AGA in genetically predisposed individuals,” the authors found.

“Notably, this typically masculine feature may be reaffirming in some transmasculine patients but for others, it may be undesirable.”

A recent retrospective cohort study of 37,826 patients demonstrated that TGD patients receiving masculinising GAH therapy were 2.5 times more likely to develop AGA as compared to cisgender women. And while the literature regarding the treatment of AGA in TGD populations was modest to date, regimens similar to that with the cisgendered population may be recommended.

In Australia, TGA-approved therapies include topical minoxidil 5% and oral finasteride. Off-label treatments include systemic minoxidil (oral or sublingual) and dutasteride. Alternative options include camouflage sprays, wigs and more invasive techniques such as hair transplantation.

TGD individuals initiating feminising GAH can see improvements in acne due to reduced sebum production, but it may predispose them to xerosis which can bring an increased risk of irritation if they are using topic acne treatments.

Highlighting the importance of a general skin care regime with frequent moisturising and less frequent acne treatments may help, the authors found.

“Spironolactone is often used as a component of feminising GAH due to its competitive inhibition against testosterone binding to cutaneous adverse receptors,” they wrote.

“It may also be a helpful treatment. Dermatologists should prescribe and manage spironolactone treatment in partnership with gender care providers to balance optimal dosages for both acne and gender affirmation while minimising adverse effects.”

Spironolactone may also be a helpful treatment for AGA in transfeminine patients. It is widely used off-label as a treatment for AGA in cisgender women, improving hair density in 30% and arresting progression in 90%.

While feminising GAH exerts a degree of hair reduction through decreased growth rate and thickness, favouring reduction in body hair as compared to facial hair, subsequent gender-affirming procedures are often required for further feminisation.

In fact, gender-affirming hair removal represented the most commonly performed facial procedure among transfeminine individuals, the authors found.

“A survey demonstrated that 85% of transwomen desired hair removal, with 94% indicating the face as the indicated site of excess hair,” they wrote.

“Gender-affirming hair removal may be associated with improved mental health outcomes and well-being. Twice daily application of topical eflornithine may reduce facial hair although is no longer sold commercially in Australia and must be privately compounded.

“Longer-lasting hair removal techniques such as laser depilation or electrolysis may obviate the need for frequent shaving, waxing or chemical depilation. However, it is important to note that barriers to these procedures include significant costs and healthcare providers’ experience with treating transgender individuals.”

The article also looked into the dermatological considerations for patients undergoing gender-affirming procedures – including chest reconstructive surgery (colloquially termed “top surgery”) and genital surgery (“bottom surgery”).

“Prior to undergoing bottom surgery, patients require permanent preoperative hair removal from donor sites,” the authors wrote.

“Intravaginal hair growth may occur following skin-lined vaginoplasty. Vaginal hair growth may lead to intravaginal irritation, infection, hairball formation, concretions of body fluids, excessive discharge, formation of keratin granulomas and overall poorer satisfaction with surgical outcomes.”

They said it was recommended to wait for three months following the final hair removal treatment to confirm no hair regrowth before proceeding with surgery.

Scarring from surgery was another reason why patients may seek a dermatology review and there were a number of potential treatments, including silicone dressings during scar aftercare; fractional resurfacing lasers for scar remodelling and improvement of texture; and vascular lasers to reduce the erythematous component.

“Significantly hypertrophic or keloid scars may be treated with intralesional corticosteroids,” the authors wrote.

“Surgical dictum proposes the avoidance of surgery while on oral isotretinoin therapy due to altered or delayed wound healing; however, the evidence in support of this remains inconclusive. Nevertheless, dermatologists should collaborate with multidisciplinary teams to optimise surgical timelines.”

The authors reported that dermatologists may also play a further role in offering minimally invasive gender-affirming procedures for TGD patients. This included the use of neurotoxins and dermal fillers for restructuring of facial features that matched gender identity.

“Minimally invasive procedures in gender affirmation should not be viewed as cosmetic treatment but rather as medically necessary care,” they wrote.

In conclusion, the authors found the provision of quality care in TGD patients was multidisciplinary and dermatologists played a crucial role in providing supportive and inclusive care.

“Understanding the unique dermatological needs of TGD individuals, including the effects of GAH therapy on skin health is essential for effective management,” they wrote.

“By fostering a safe and respectful environment, Australian dermatologists may contribute to the improved health outcomes of TGD patients.”