The transitioning patient

Dr. Day

At the recent Cosmetic Surgery Forum in Nashville, Tenn., Doris Day, M.D., a board-certified dermatologist and self-professed doctor of self-esteem in New York City, presented on a timely and sensitive topic. In her session, “Hormones and Dermatology,” Dr. Day shared her experience treating a transitioning patient who challenged how she thinks about gender.

When she started the transitioning process with her patient, Dr. Day says she had a black and white perception of the genders.

“When I think of transitioning from male to female, I'm also thinking binary male to binary female,” she says.

For this patient, however, she found a new shade of gray.

“What I learned is that this journey for this patient really wasn't in any way binary,” says Dr. Day.

To date, the healthcare industry has struggled with a disparity of care for this patient population because of cultural ignorance and a lack of treatment knowledge.

In a study published in The American Public Health Association, authors examined existing procedures and policies for identifying LGTBQ+-competent physicians at U.S. academic faculty practices.¹

They found that out of the 138 accredited U.S. academic faculty practices studied, “Few participants had existing procedures (9%) or policies (4%) to identify [LGBTQ+]-competent physicians…. Sixteen percent of participants reported having comprehensive [LGBTQ+]-competency training, and 52% reported having no training. Of note, 80% of participants indicated interest to do more to address these issues.”

As patients consider undergoing transition, medical advice and treatments from dermatologists like Dr. Day are crucial to a positive personal process.

A study from the Journal of the American Academy of Dermatology suggests, “Dermatologists may have a tremendous impact on the lives of transgender individuals who seek to realize their gender identity.”²

For Dr. Day, she says that she realized, “I have to question my own judgment and my own perception of my patients and be respectful of where they are, and how to approach them.”

She says that the process of transitioning can take multiple years and that it’s an emotional experience for her patients.

“The courage to actually go through that is a lot… then there becomes [the] commitment and courage to make that transition to match what you see inside with what you see on the outside,” she says.

The first step, says Dr. Day, is hormone therapy, which for patients transitioning from male to female means lowering the effect of testosterone and raising the effect of estrogen.

By starting with hormones, the external appearance begins to change.

“What we see from this is that the skin becomes smoother, there's less facial hair,” she says.

She then uses fillers and botulinum toxin, along with other aesthetic devices to “create a little bit more of an arch to the brow, higher cheekbones [and] more of a heart-shaped oval face as opposed to a square face shape.”

She says that unlike her original perception, her patient didn’t have an end goal of looking stereotypically female, but that it all came down to how she personally wanted to be seen, whether that be to herself, or the public.

“She taught me so much in this journey, but to see her joy at seeing her features, which weren't classic female, but we're somewhere along that way, was so inspiring,” she says.

It’s the patient’s choice on how far to go within their transition, says Dr. Day, noting that many transgender patients no longer elect to undergo top or bottom gender confirmation surgeries.

“Where we stop is where they're ready to pause,” she says. “Then we pick it up again when they're ready to pursue the next step.”

References:

1. Dhingra N, Bonati LM, Wang EB, Chou M, Jagdeo J. Medical and aesthetic procedural dermatology recommendations for transgender patients undergoing transition. J Am Acad Dermatol. 2019;80(6):1712-1721.

2. Joshua Khalili, Lucinda B. Leung, and Allison L. Diamant, 2015: Finding the Perfect Doctor: Identifying Lesbian, Gay, Bisexual, and Transgender–Competent Physicians. Am J Public Health. 2015;105(6):1114-9.