Understanding Dermatological Needs of Gender-Diverse Patients

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Transgender or gender diverse (TGD) individuals, individuals whose gender identity is incongruent with their sex assigned at birth, often experience high rates of mental health conditions.¹ Researchers have hypothesized this is a result of discrimination in nearly all aspects of life, from housing to employment, social exclusion, bullying, and assault. Health care is no exception, according to astudy that found that 28% of TGD Australians experienced discrimination in medical settings.² Because of the relationship between endocrinology and the skin, and the significant part that hair plays in gender expression, researchers noted that dermatologists will likely be involved in caring for TGD patients. With this in mind, they set out to review appropriate terminology critical for TGD care, gender affirmation in the Australian healthcare landscape, dermatological considerations for TGD patients, and general approaches to management.³

Terminology

In terms of language, researchers noted that using an individual’s correct names and pronouns is an important way to affirm gender and demonstrate understanding.⁴ The study stated that medical records should reflect these changes, to ensure that clerical, reception, nursing, allied health and medical staff can avoid misgendering the patient. There are many terms to describe gender, including binary terms such as male or female, as well as non-binary, genderfluid, genderqueer, demi-boy, demi-girl, transmasculine, transfeminine, agender, and many more. Researchers noted that membership to multiple minority groups, such as Indigenous Australians, may see cumulative barriers to treatment.⁵ While gender diversity is an ancient concept and part of many First Nation's cultures, they added that the health disparities of this group are a growing area of research that requires further attention.⁶

Gender-Affirming Care in Australia 

In Australia, guidelines for gender-affirming care include the Australian standards for TGD children and adolescents, hormonal management for adult TGD individuals, and informed consent standards for hormone therapy.^7-9 Researchers noted this care typically involves a multidisciplinary team providing social, medical, and legal support, including psychological and peer support. Social transitions may involve changes in gender expression, names, or pronouns, while some individuals may seek medical interventions like hormonal or surgical treatments. Other specific supports available for TGD individuals include vocal training, psychological care and fertility counselling for patients commencing gender-affirming hormones (GAH).⁷

Puberty suppression, using gonadotropin-releasing hormone (GnRH) analogues, can halt the development of secondary sexual characteristics and is most effective if started at Tanner stage 2.7 Although puberty suppression can lead to reduced bone density, recent data suggest it recovers after hormone therapy begins. Australian guidelines recommend monitoring bone density during treatment.¹⁰ However, the study stated that GnRH analogues are not subsidized by the Pharmaceutical Benefits Scheme for this purpose, making them costly for some patients.

Dermatologists and Supporting Gender-Diverse Patients

Researchers found that key qualities valued by TGD patients include provider professionalism, knowledge, and sensitivity, which are more important than symbolic gestures like stickers or brochures. Asking about gender identity, pronouns, and sexual behaviors should be done respectfully and framed as a standard practice, such as with a statement such as, “Our clinic is an inclusive and safe space for all our patients.” In emergency settings, the study stated that TGD patients might prefer to provide this information nonverbally.¹¹

The study stated that patient intake forms, medical records, and documentation should reflect diversity. Using preferred names and pronouns and confirming them regularly is crucial, especially for patients exploring their gender identity. For younger patients, researchers noted that confidential discussions without parents may be necessary. Examinations should follow a trauma-informed approach, emphasizing sensitivity, transparency, consent, and cultural understanding as outlined in AusPATH guidelines.⁹

Dermatological Considerations in Gender-Affirming Care

Acne Vulgaris:

• Masculinising GAH: Androgens in testosterone therapy increase sebum production, leading to higher acne rates. TGD patients on masculinising GAH experience acne 2.4 times more than cisgender women and 4.1 times more than cisgender men. Acne prevalence rises from 6.3% to 31.1% after starting masculinising GAH, with peak incidence in the first 6 months. Risk factors include younger age of initiation, higher testosterone levels, and smoking. Management includes benzoyl peroxide, topical retinoids, and antibiotics, with additional liver monitoring if tetracyclines are used.
• Feminising GAH: Acne often improves due to reduced sebum production, but xerosis may increase irritation from topical treatments. Spironolactone, used in feminisingGAH, may help with acne but requires careful dosage management to balance efficacy with adverse effects.¹²

Hair:

• Transmasculine Patients: Androgens may increase facial and body hair but also cause AGA in predisposed individuals. AGA treatment options include topical minoxidil, oral finasteride, and dutasteride. Finasteride is effective but may interfere with testosterone therapy, so starting it after 5 years of GAH is a conservative approach. Monitoring for pregnancy is crucial when using finasteride due to teratogenic risks.
• Transfeminine Patients: Spironolactone may improve AGA and is commonly used off-label. Other treatments include topical minoxidil and oral finasteride, with considerations for potential interference with feminizing hormones.¹³

Gender-Affirming Procedures:

• Preoperative Hair Removal: Essential for bottom surgery to avoid complications like intravaginal hair growth. Laser hair removal is preferred for efficiency and cost.
• Post-Surgical Care: Silicone dressings and lasers can improve scar appearance. The impact of isotretinoin on wound healing remains debated; thus, coordination with surgical teams is vital.¹⁴

Minimally Invasive Procedures:

• Neurotoxins and Dermal Fillers: Used to modify facial features to align with gender identity. Procedures should be considered medically necessary and not merely cosmetic.¹⁵

Other Considerations:

• HIV Screening: TGD individuals have higher HIV rates than cisgender individuals. Risk-based screening and prevention, including PrEP, are recommended.¹⁶
• Transdermal Hormone Patches: Can cause allergic or irritant contact dermatitis. Alternatives and management strategies include adjusting application sites and pre-treating with corticosteroids.¹⁷
• Dermatoses: Conditions such as testosterone blockade melasma and hidradenitis suppurativa may occur. Treatment should consider GAH therapy's impact and the patient’s psychosocial context.³
• Skin Cancer Risk: Evidence on GAH therapy's effect on skin cancer incidence is limited, with some studies suggesting no increased risk. Behavioral factors may influence skin cancer prevalence in gender non-conforming individuals.¹⁸

Researchers noted that dermatologists must tailor care to the unique needs of each TGD patient, considering both dermatological and psychosocial factors in treatment and management.

Conclusion

The study found that providing quality care for TGD patients requires a multidisciplinary approach, with dermatologists playing a key role. They must understand the unique dermatological needs of TGD individuals, including the impacts of GAH therapy on skin health. By creating a safe and respectful environment, Australian dermatologists can significantly enhance the health outcomes of TGD patients.

References

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9. AusPATH. Australian informed consent standards of care for gender affirming hormone therapy. 2022. Accessed July 30, 2023. https://auspath.org.au/wp-content/uploads/2022/05/AusPATH_Informed-Consent-Guidelines_DIGITAL.pdf
10. Dubois V, Ciancia S, Doms S, et al. Testosterone restores body composition, bone mass, and bone strength following early puberty suppression in a mouse model mimicking the clinical strategy in trans boys. J Bone Miner Res. 2023;38(10):1497-1508. doi:10.1002/jbmr.4832
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