- Email: [email protected]
A potential role for the dermatologist in the physical transformation of transgender people: A survey of attitudes and practices within the transgender community
ORIGINAL
ARTICLE
A potential role for the dermatologist in the physical transformation of transgender people: A survey of attitudes and practices within the transgender community Brian A. Ginsberg, MD,a Marcus Calderon, BS,b Nicole M. Seminara, MD,c and Doris Day, MD, MAa,d New York, New York, and Stanford, California Background: There are an estimated 700,000 or more transgender people in the United States, however their dermatologic needs are not fully established in the medical literature. Unique needs relate to hormone therapy, prior surgeries, and other aspects of physical transitioning. Objectives: By examining attitudes and practices of transgender individuals, we aimed to identify areas for which dermatologists could contribute to their physical transformation. Methods: This cross-sectional study used an anonymous online survey, distributed via lesbian, gay, bisexual, and transgender organizations; social media; and at targeted locations and events. Results: A total of 327 people completed the survey (63% men, 29% women, 9% other). Most transgender women indicated that their face was most imperative to have changed, whereas men noted their chest, in turn influencing procedures. Of women’s facial procedures, hair removal predominated, followed by surgery then injectables, mostly performed by plastic surgeons. Hormone-induced facial effects varied, usually taking over 2 years for maximal effect. When choosing procedures, money was the major barrier and good aesthetic outcome the primary concern. Participants did not think that facial procedures necessitate the currently accepted prerequisites for chest and genital surgery. Limitations: This study has limited size and convenience sampling. Conclusion: Dermatologists could contribute to the physical transformation of transgender patients through noninvasive procedures. ( J Am Acad Dermatol http://dx.doi.org/10.1016/j.jaad.2015.10.013.) Key words: dermatology; filler; laser; LGBT; neurotoxin; procedures; skin; surgery; transgender.
t least 0.3% of the US population, or 700,000 people, identify as transgender, which with data collection about the transgender population only now being performed, many consider an underestimation.1 Nevertheless, in only the past few years, their presence and issues gained heightened attention in society and media.2 This holds true for medical literature, with a paucity of articles
A
addressing the needs of the transgender community, especially in dermatology. A transgender individual is anyone whose selfidentified gender does not match their assigned sex at birth.3 Although historical definitions have defined ‘‘transgender’’ or ‘‘transsexual’’ (to some, a pejorative) by surgeries or the way one performed gender-stereotyped social behaviors, ‘‘transgender’’
From the Ronald O. Perelman Department of Dermatology, New York University Langone Medical Centera; New York University School of Medicineb; Department of Dermatology, Stanford University School of Medicinec; and Day Dermatology and Aesthetics, New York.d The Ronald O. Perelman Department of Dermatology at New York University Langone Medical Center purchased the SurveyMonkey membership. Conflicts of interest: None declared.
Accepted for publication October 22, 2015. Reprint requests: Brian A. Ginsberg, MD, Ronald O. Perelman Department of Dermatology, New York University Langone Medical Center, 240 E 38 St, 11th Floor, New York, NY 10016. E-mail: [email protected]. Published online December 2, 2015. 0190-9622/$36.00 Ó 2015 by the American Academy of Dermatology, Inc. http://dx.doi.org/10.1016/j.jaad.2015.10.013
1
2 Ginsberg et al
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has become an umbrella term for anyone whose Review Board granted an exemption from review gender identity and chromosomal sex are incon(no. i14-00217, January 21, 2014). Information gruent, or to anyone whose gender does not about the survey was distributed at transgender conform to the typical binary. conferences; medical clinics; lesbian, gay, bisexual, The dermatologist’s role in the care of transgender and transgender centers; and community events. The patients is multifaceted.4 Exogenous hormones majority of in-person interaction occurred at New affect sebum production and hair development, York City establishments and at the Philadelphia resulting in xerosis from Trans Health Conference, estrogens, or potential the largest health-related CAPSULE SUMMARY acne and male-pattern hair conference for the transloss from testosterone.5,6 gender community. To Transgender individuals are seeking Condyloma and HPVobtain a more representative procedures for physical transformation, associated skin cancers have national sample, word-ofbut the dermatologist’s role in this been reported on the neomouth spread was encourprocess is undefined. genitalia of women who aged, especially with e-mail Facial transformation is desired and have undergone gender contact via lesbian, gay, sought out by transgender individuals, confirmation surgery.7-11 bisexual, and transgender especially women, although barriers and organizations and through Furthermore, this population concerns exist. social media. Participants has elevated rates of HIV, had to be at least 18 years carrying its own burden of Dermatologists can provide injectable old, live in the United States, associated dermatoses.12,13 and laser procedures for facial and identify as transgender. What remains to be elucimodification, helping in the physical Responses were anonymous dated is how the dermatolotransitioning process. and every question was gist can be of further aid by optional. The survey addressing the physical tranremained open from January to September 2014. sitioning process.14 Neurotoxin could be used to Descriptive statistics, including means and medians feminize the forehead, eyebrows, or periorbital skin, for continuous variables and frequency tables for and with masseter injections could make a squaredcategorical variables, were generated using Excel off masculine face appear more heart-shaped. Fillers (Microsoft Corp, Redmond, WA) and SAS 9.4 (SAS could make the cheeks and chin appear more Institute Inc, Cary, NC) software. Validation was masculine or feminine, depending on placement, assessed informally by cross-referencing related or give a more full, feminine lip. Currently, many questions for consistency of responses. transgender people are instead seeking plastic Of note, the use of gender identifiers (ie, men, surgery, frequently with great outcomes, but with women, other) in this paper reflects how the subject sometimes highly invasive procedures.15,16 Of self-identified, irrespective of sex at birth, hormone concern, high rates of procedures, particularly use, or procedures done. silicone injections, from nonmedical personnel have been reported, often with devastating and disfiguring complications.17-19 RESULTS We therefore set out to determine the current Demographics attitudes and practices of the transgender community A total of 327 individuals participated in this study with respect to physical transitioning. In doing so, (Table I). Some questions were not answered by all we hope to identify opportunities where dermatorespondents. Overall, 63% of participants identified logic procedures may provide safe and noninvasive as transgender men, 29% as transgender women, and options for this process. In addition, we aim to 9% as other. Those who self-identified as ‘‘other’’ investigate what concerns and barriers are helping to could write in their own gender, most commonly dictate decisions when choosing care. stating ‘‘genderqueer’’ (n = 12), but also ‘‘nonbinary,’’ ‘‘pan-gender,’’ ‘‘agender,’’ ‘‘androgynous,’’ ‘‘crossdresser,’’ ‘‘trans,’’ ‘‘bigendered,’’ ‘‘chimera,’’ and METHODS ‘‘queer.’’ The men were on average 29 years old, In this cross-sectional study, an online questionwhereas the women were on average 45 years old. naire was developed using SurveyMonkey (www. The median annual income of all respondents was surveymonkey.com, December 2013) to assess $20,000. attitudes and practices of the transgender community Of the 215 respondents who indicated their place with respect to physical transitioning. The New York of residence, 41 states (including the District of University Langone Medical Center Institutional d
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Table I. Demographics Transgender Transgender men women Other
n (%) Median age, y Age range, y Median income, US$
205 (63) 26 18-57 18,000
94 (29) 45.5 18-93 25,000
Overall
28 (7) 327 (100) 24 29 19-41 18-93 5100 20,000
Columbia) were represented, with 20% from New York; 7% from each of California, Massachusetts, and Pennsylvania; and the remaining states with up to 4% each. The majority (of 224 respondents) heard of the survey through social media (65%), followed by through an organization’s e-mail (14%), at a community center or event (8%), through a friend (8%), at a health care facility (3%), or by another unlisted means (3%). Body part priority for transitioning When asked what body parteface, chest, or genitalsewould be preferred to change first if money was not an issue, the men (n = 174) prioritized the chest over their face or genitals. Of the women (n = 85), more people chose their face than their chest or genitals. Of participants who have had any procedure (including neurotoxin, fillers, and surgery, but not including laser), the men (n = 55) had mostly chest reductions, as opposed to procedures on their face or genitals. Also in line with their preferences, women (n = 30) reported having more nonlaser facial procedures than those for their chest or genitals (Fig 1). Face procedures Of women who reported having any facial procedure including laser (n = 48), the most common facial procedure was laser hair removal, followed by surgery, then injectables, including neurotoxin and filler (Fig 2). Men reported substantially fewer facial procedures overall (n = 6), including laser hair removal (n = 3), surgery (n = 2), and injectables (n = 1). Of those who had injectables (n = 21), most went to a plastic surgeon (n = 12). Other practitioners who performed these procedures were dermatologists (n = 3), primary care physicians (n = 3), urologists (n = 2), endocrinologists (n = 2), and an ophthalmologist (n = 1). Hormone effects The participants on hormone therapy were asked about the effects of these hormones on specific facial features. For men (n = 118), almost everyone
experienced changes in facial hair, with the next most frequent changes being of the jaw angle, chin shape, and cheek shape, with other features also being affected at a lower rate. For women (n = 71), facial hair was also most frequently affected, with lip fullness and cheek shape following in next highest frequencies (Fig 3, A). Looking at those who have been on hormone therapy for at least 2 years (n = 97), when asked how long it took for the hormones to achieve maximal effect in causing transition-related physical changes, 72% reached this point after 2 years or were still changing, and 14% experienced maximal effect between the first and second year of therapy. These frequencies were similar when broken down by gender (Fig 3, B). Concerns and barriers Participants were asked to select, from a list of possible concerns, which was a major concern, minor concern, or not a concern at all when considering a procedure for transitioning (Fig 4, A). The concern most frequently noted to be a major concern of respondents (n = 226) was that the outcome of the procedure looked good (91%), with the other listed concerns also frequently chosen, which included whether the procedure required surgery, left a scar, had a risk of complications, was permanent, was not permanent, or involved anesthesia. Participants also could write their own concerns, with 1 person expressing concern about the procedure affecting functionality and another questioning whether it would address their underlying dysphoria. From a list of possible barriers, participants most frequently chose money/cost as a major barrier (87%). The other options for major barriers were access to care, having a support system, laws, and stigma (Fig 4, B). Written-in responses included being uninformed and time needed to undergo the procedure. Guidelines Participants (n = 231) were asked whether they thought it necessary to see a mental health professional, be on hormones for 1 year, and/or live as their self-identified gender for 1 year before undergoing facial procedures. This was based on the guidelines of the World Professional Association for Transgender Health, which suggest the above 3 practices as prerequisites for genital reconstruction.20 Before nonpermanent facial procedures, 5% believed that a mental health professional should be seen, 6% thought that one should be on hormones,
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Fig 1. The first body part one would change, if money were not an issue, as compared with body parts already treated with nonlaser procedures (including neurotoxin, filler, and surgery).
Fig 2. Of the women who obtained any procedure on the face, percent who had injectables (neurotoxin or filler), surgery, and/or laser hair removal (LHR).
and 2% believed that the person should live as their self-identified gender. For permanent procedures, these respective percentages were 22%, 23%, and 21%.
DISCUSSION It is often presumed that genital surgery is the primary procedure-related goal of transgender people. In this study, neither men nor women had this as their top priority, choosing their chest or face, respectively, for transitioning procedures. This is potentially because of its implications as a means to pass as one’s self-identified gender in society.21 Testosterone may adequately masculinize a face, but without chest binding or getting a mastectomy, it may be challenging to present oneself as a man. On the contrary, estrogens may help grow breast tissue, but are often not sufficient to feminize a face. Genitalia, regardless of hormonal effects, are not as discernable in public. Of all facial procedures, our female participants are getting laser hair removal the most. It is unclear if this is because of true priorities, or reflects other factors, such as accessibility and cost. What is evident is that estrogen, although effective in removing body hair, frequently does not completely eliminate facial hair, but merely decreases its size and density.4
Therefore, in an effort to either remove the ‘‘5 o’clock shadow’’ or simply the thought of being a woman who shaves her beard, permanent facial epilation can be life changing.22 Women were also undergoing surgical procedures more frequently than receiving injectables for facial transformation. This may be because a permanent outcome is desired, but may reflect a lack of knowledge of options available or rather access to care in the community, among other reasons. Injectables may be a more affordable and accessible option and can give a dramatic and effective result, addressing the largest barrier (money) and concern (outcome) of our participants. However, the transgender community is on average at a lower income level than the general population, as seen in our study sample as well, so injectable procedures may remain cost-prohibitive.23 At this time, although many insurances cover chest/breast and genital reconstruction, facial procedures, both noninvasive and surgical, are considered cosmetic.24 Cost aside, injectables may be the only option for facial modification if the patient is not a surgical candidate or not yet interested in making a permanent change. Individuals may also wish to avoid permanent surgery until they have seen the maximal effect from the hormones. For most of our participants, this happened after 2 years or was ongoing. Aside from hair, men were reporting changes in their cheeks, chin, and jaw, and women in their cheeks and lips, all areas addressable with cosmetic fillers. For those who may ultimately want permanence, injectables may serve as a bridge while hormonal changes take effect, and can also help the patient get an image of how their face could appear before undergoing anything invasive and fixed. Of those who were getting injectables, most sought care from plastic surgeons, likely for varied reasons. They may be already seeing surgeons for other transition-related procedures. Traditional advertising may also contribute to this disparity,
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Fig 3. A, The percent of participants taking hormones who experienced an effect of the hormone on the specific facial feature. B, The amount of time it took until the maximum effect of hormone therapy on physical transformation was experienced (for those on hormones for at least 2 years).
Fig 4. The factors thought to be major concerns (A) and barriers (B) with regard to obtaining a procedure for transitioning.
including several plastic surgeons who specifically market to the transgender population. Plastic surgeons play a critical role in physical transitioning, and are competent in injectable procedures; this merely exposes an opportunity in which dermatologists can also help make a difference. Furthermore, many dermatology practices may not be deemed culturally competent to a transgender patient.3,25,26 Staff should be trained about addressing transgender clientele, including proper use of pronouns and identifiers. Intake forms should be all-inclusive, asking about ‘‘gender’’ rather than ‘‘sex,’’ and leaving a write-in option for ‘‘other.’’ With electronic records, allowing for such versatility will have to be addressed on a larger scale. With greater patient comfort in doctors’ offices, they may be less likely to seek precarious care from nonmedical personnel. Finally, we asked about opinions about possible preprocedure qualifications, as there currently are none established. Although no law dictates what must be done before gender confirmation surgery (chest and genital surgery), the World Professional Association for Transgender Health publishes guidelines that most physicians follow, recommending documented gender dysphoria and, for some
procedures, 1 year of hormone therapy and living as the ultimate gender for 1 year.20 Although they do not propose these guidelines for facial procedures, we were interested in opinions as to if they should. Most individuals believed that these guidelines were not necessary for any type of facial procedure, however of those who did, this was mostly restricted to procedures that were permanent. Our survey is limited in its ability to be generalized to the transgender community as a whole. This generalizability is qualified by the potential convenience sample created by the restricted means of survey distribution, even with the survey reaching 41 states. We had a disproportionately higher percentage of men than women completing the survey. Although there are no clear data about gender breakdown of the US transgender population, Census Bureau analysis of name changes of suspected transgender individuals showed that 65% were by transgender men and 35% by women, providing some insight into the potential distribution within our study.27 The study sample size is also prohibitive, especially in some questions with very low response rates. Furthermore, the survey instrument itself was not formally assessed in terms of reliability and
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validity, using only cross-referencing as a tool to determine if responses were consistent. Nonetheless, the purpose of this study was not to determine exact rates of actions, but rather to investigate need and opportunity for dermatologists to aid in transgender care. Conclusions Aside from case reports of injectable filler use, to our knowledge there has been no clear study of the attitudes and practices of the transgender community with respect to procedural dermatology.17 Our study showed that facial transformation is of high importance in this community, especially for women. Dermatologists have an opportunity to make a difference in this process, providing safe and noninvasive options (including neurotoxin, fillers, and laser hair removal) for facial transformation, in addition to routine and focused medical dermatology. In doing so, our transgender patients may get further alleviation for their gender dysphoria, and like our cis-gender patients (those whose gender identity matches their assigned sex at birth), they may be more comfortable and confident in their appearance. REFERENCES 1. Gates G. How many people are lesbian, gay, bisexual, and transgender? A report of the Williams Institute. Los Angeles (CA): Williams Institute, UCLA School of Law; 2011 2. Steinmetz, K. The transgender tipping point. Time. May 29, 2014: cover. 3. GLAAD. GLAAD media reference guideetransgender issues. 2015. Available from: URL: www.glaad.org/reference/trans gender. Accessed October 2015. 4. Katz KA, Furnish TJ. Dermatology-related epidemiologic and clinical concerns of men who have sex with men, women who have sex with women, and transgender individuals. Arch Dermatol. 2005;141(10):1303-1310. 5. Giltay EJ, Gooren LJ. Effects of sex steroid deprivation/ administration on hair growth and skin sebum production in transsexual males and females. J Clin Endocrinol Metab. 2000; 85(8):2913-2921. 6. Wierckx K, Van de Peer F, Verhaeghe E, et al. Short- and long-term clinical skin effects of testosterone treatment in trans men. J Sex Med. 2014;11(1):222-229. 7. Liguori G, Trombetta C, Bucci S, et al. Condylomata acuminata of the neovagina in a HIV-seropositive male-tofemale transsexual. Urol Int. 2004;73(1):87-88. 8. Wasef W, Sugunendran H, Alawattegama A. Genital warts in a transsexual. Int J STD AIDS. 2005;16(5):388-389. 9. Yang C, Liu S, Xu K, Xiang Q, Yang S, Zhang X. Condylomata gigantea in a male transsexual. Int J STD AIDS. 2009;20(3): 211-212. 10. Fernandes HM, Manolitsas TP, Jobling TW. Carcinoma of the neovagina after male-to-female reassignment. J Low Genit Tract Dis. 2014;18(2):E43-45.
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11. Harder Y, Erni D, Banic A. Squamous cell carcinoma of the penile skin in a neovagina 20 years after male-to-female reassignment. Br J Plast Surg. 2002;55(5):449-451. 12. Centers for Disease Control and Prevention. HIV among transgender people. Atlanta: 2013 Dec. Available from: URL: http:// www.cdc.gov/hiv/risk/transgender/index.html. Accessed October 2015. 13. Zancanaro PC, McGirt LY, Mamelak AJ, Nguyen RH, Martins CR. Cutaneous manifestations of HIV in the era of highly active antiretroviral therapy: an institutional urban clinic experience. J Am Acad Dermatol. 2006;54(4):581-588. 14. Ginsberg, B. Transforming skin: transgender dermatology. Huffington Post. 2013. Available from: URL: http://www. huffingtonpost.com/brian-ginsberg-md/transforming-skin-trans gender-dermatology_b_4122712.html. Accessed October 2015. 15. Altman K. Facial feminization surgery: current state of the art. Int J Oral Maxillofac Surg. 2012;41(8):885-894. 16. Becking AG, Tuinzing DB, Hage JJ, Gooren LJ. Transgender feminization of the facial skeleton. Clin Plast Surg. 2007;34(3): 557-564. 17. Murray R. Transgender woman arrested after injecting Fix-AFlat into patient’s rear end. 2011. Available from: URL: http://www. nydailynews.com/news/crime/transgender-woman-arrestedinjecting-fix-a-flat-patient-rear-article-1.980273. Accessed June 15, 2014. 18. Wilson E, Rapues J, Jin H, Raymond HF. The use and correlates of illicit silicone or ‘‘fillers’’ in a population-based sample of transwomen, San Francisco, 2013. J Sex Med. 2014;11: 1717-1724. 19. Styperek A, Bayers S, Beer M, Beer K. Nonmedical-grade injections of permanent fillers: medical and medicolegal considerations. J Clin Aesthet Dermatol. 2013;6(4):22-29. 20. World Professional Association for Transgender Health. Standards of care for the health of transsexual, transgender and gender nonconforming people. 7th version. 2012. Available from: URL: www.wpath.org. Accessed October 2015. 21. Godfrey C. Transgender men and women discuss the politics of ‘‘passing.’’ Vice Media. March 2015. Available from: URL: www.vice.com/read/passing-when-youre-transgender. Accessed October 2015. 22. James A. Hair removal. Trans road map. 2015. Available from: URL: www.tsroadmap.com/physical/hair. Accessed October 2015. 23. Grant JM, et al. Injustice at every turn: a report of the national transgender discrimination survey. Washington (DC): National Center for Transgender Equality and National Gay and Lesbian Task Force; 2011. 24. Human Rights Campaign. Finding insurance for trans gender-related healthcare. Available from: URL: www.hrc.org/ resources/entry/finding-insurance-for-transgender-relatedhealthcare. Accessed August 2015. 25. Coren JS, Coren CM, Pagliaro SN, Weiss LB. Assessing your office for care of lesbian, gay, bisexual, and transgender patients. Health Care Manag. 2011;30(1):66-70. 26. Robinson A. The transgender patient and your practice: what physicians and staff need to know. J Med Pract Manage. 2010; 25(6):364-367. 27. Cerf Harris B. Likely transgender individuals in US federal administrative records and the 2010 Census. US Census Bureau. 2015. Available from: http://www.census.gov/srd/ carra/15_03_Likely_Transgender_Individuals_in_ARs_and_ 2010Census.pdf. Accessed October 2015.
ARTICLE
A potential role for the dermatologist in the physical transformation of transgender people: A survey of attitudes and practices within the transgender community Brian A. Ginsberg, MD,a Marcus Calderon, BS,b Nicole M. Seminara, MD,c and Doris Day, MD, MAa,d New York, New York, and Stanford, California Background: There are an estimated 700,000 or more transgender people in the United States, however their dermatologic needs are not fully established in the medical literature. Unique needs relate to hormone therapy, prior surgeries, and other aspects of physical transitioning. Objectives: By examining attitudes and practices of transgender individuals, we aimed to identify areas for which dermatologists could contribute to their physical transformation. Methods: This cross-sectional study used an anonymous online survey, distributed via lesbian, gay, bisexual, and transgender organizations; social media; and at targeted locations and events. Results: A total of 327 people completed the survey (63% men, 29% women, 9% other). Most transgender women indicated that their face was most imperative to have changed, whereas men noted their chest, in turn influencing procedures. Of women’s facial procedures, hair removal predominated, followed by surgery then injectables, mostly performed by plastic surgeons. Hormone-induced facial effects varied, usually taking over 2 years for maximal effect. When choosing procedures, money was the major barrier and good aesthetic outcome the primary concern. Participants did not think that facial procedures necessitate the currently accepted prerequisites for chest and genital surgery. Limitations: This study has limited size and convenience sampling. Conclusion: Dermatologists could contribute to the physical transformation of transgender patients through noninvasive procedures. ( J Am Acad Dermatol http://dx.doi.org/10.1016/j.jaad.2015.10.013.) Key words: dermatology; filler; laser; LGBT; neurotoxin; procedures; skin; surgery; transgender.
t least 0.3% of the US population, or 700,000 people, identify as transgender, which with data collection about the transgender population only now being performed, many consider an underestimation.1 Nevertheless, in only the past few years, their presence and issues gained heightened attention in society and media.2 This holds true for medical literature, with a paucity of articles
A
addressing the needs of the transgender community, especially in dermatology. A transgender individual is anyone whose selfidentified gender does not match their assigned sex at birth.3 Although historical definitions have defined ‘‘transgender’’ or ‘‘transsexual’’ (to some, a pejorative) by surgeries or the way one performed gender-stereotyped social behaviors, ‘‘transgender’’
From the Ronald O. Perelman Department of Dermatology, New York University Langone Medical Centera; New York University School of Medicineb; Department of Dermatology, Stanford University School of Medicinec; and Day Dermatology and Aesthetics, New York.d The Ronald O. Perelman Department of Dermatology at New York University Langone Medical Center purchased the SurveyMonkey membership. Conflicts of interest: None declared.
Accepted for publication October 22, 2015. Reprint requests: Brian A. Ginsberg, MD, Ronald O. Perelman Department of Dermatology, New York University Langone Medical Center, 240 E 38 St, 11th Floor, New York, NY 10016. E-mail: [email protected]. Published online December 2, 2015. 0190-9622/$36.00 Ó 2015 by the American Academy of Dermatology, Inc. http://dx.doi.org/10.1016/j.jaad.2015.10.013
1
2 Ginsberg et al
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has become an umbrella term for anyone whose Review Board granted an exemption from review gender identity and chromosomal sex are incon(no. i14-00217, January 21, 2014). Information gruent, or to anyone whose gender does not about the survey was distributed at transgender conform to the typical binary. conferences; medical clinics; lesbian, gay, bisexual, The dermatologist’s role in the care of transgender and transgender centers; and community events. The patients is multifaceted.4 Exogenous hormones majority of in-person interaction occurred at New affect sebum production and hair development, York City establishments and at the Philadelphia resulting in xerosis from Trans Health Conference, estrogens, or potential the largest health-related CAPSULE SUMMARY acne and male-pattern hair conference for the transloss from testosterone.5,6 gender community. To Transgender individuals are seeking Condyloma and HPVobtain a more representative procedures for physical transformation, associated skin cancers have national sample, word-ofbut the dermatologist’s role in this been reported on the neomouth spread was encourprocess is undefined. genitalia of women who aged, especially with e-mail Facial transformation is desired and have undergone gender contact via lesbian, gay, sought out by transgender individuals, confirmation surgery.7-11 bisexual, and transgender especially women, although barriers and organizations and through Furthermore, this population concerns exist. social media. Participants has elevated rates of HIV, had to be at least 18 years carrying its own burden of Dermatologists can provide injectable old, live in the United States, associated dermatoses.12,13 and laser procedures for facial and identify as transgender. What remains to be elucimodification, helping in the physical Responses were anonymous dated is how the dermatolotransitioning process. and every question was gist can be of further aid by optional. The survey addressing the physical tranremained open from January to September 2014. sitioning process.14 Neurotoxin could be used to Descriptive statistics, including means and medians feminize the forehead, eyebrows, or periorbital skin, for continuous variables and frequency tables for and with masseter injections could make a squaredcategorical variables, were generated using Excel off masculine face appear more heart-shaped. Fillers (Microsoft Corp, Redmond, WA) and SAS 9.4 (SAS could make the cheeks and chin appear more Institute Inc, Cary, NC) software. Validation was masculine or feminine, depending on placement, assessed informally by cross-referencing related or give a more full, feminine lip. Currently, many questions for consistency of responses. transgender people are instead seeking plastic Of note, the use of gender identifiers (ie, men, surgery, frequently with great outcomes, but with women, other) in this paper reflects how the subject sometimes highly invasive procedures.15,16 Of self-identified, irrespective of sex at birth, hormone concern, high rates of procedures, particularly use, or procedures done. silicone injections, from nonmedical personnel have been reported, often with devastating and disfiguring complications.17-19 RESULTS We therefore set out to determine the current Demographics attitudes and practices of the transgender community A total of 327 individuals participated in this study with respect to physical transitioning. In doing so, (Table I). Some questions were not answered by all we hope to identify opportunities where dermatorespondents. Overall, 63% of participants identified logic procedures may provide safe and noninvasive as transgender men, 29% as transgender women, and options for this process. In addition, we aim to 9% as other. Those who self-identified as ‘‘other’’ investigate what concerns and barriers are helping to could write in their own gender, most commonly dictate decisions when choosing care. stating ‘‘genderqueer’’ (n = 12), but also ‘‘nonbinary,’’ ‘‘pan-gender,’’ ‘‘agender,’’ ‘‘androgynous,’’ ‘‘crossdresser,’’ ‘‘trans,’’ ‘‘bigendered,’’ ‘‘chimera,’’ and METHODS ‘‘queer.’’ The men were on average 29 years old, In this cross-sectional study, an online questionwhereas the women were on average 45 years old. naire was developed using SurveyMonkey (www. The median annual income of all respondents was surveymonkey.com, December 2013) to assess $20,000. attitudes and practices of the transgender community Of the 215 respondents who indicated their place with respect to physical transitioning. The New York of residence, 41 states (including the District of University Langone Medical Center Institutional d
d
d
Ginsberg et al 3
J AM ACAD DERMATOL
VOLUME jj, NUMBER j
Table I. Demographics Transgender Transgender men women Other
n (%) Median age, y Age range, y Median income, US$
205 (63) 26 18-57 18,000
94 (29) 45.5 18-93 25,000
Overall
28 (7) 327 (100) 24 29 19-41 18-93 5100 20,000
Columbia) were represented, with 20% from New York; 7% from each of California, Massachusetts, and Pennsylvania; and the remaining states with up to 4% each. The majority (of 224 respondents) heard of the survey through social media (65%), followed by through an organization’s e-mail (14%), at a community center or event (8%), through a friend (8%), at a health care facility (3%), or by another unlisted means (3%). Body part priority for transitioning When asked what body parteface, chest, or genitalsewould be preferred to change first if money was not an issue, the men (n = 174) prioritized the chest over their face or genitals. Of the women (n = 85), more people chose their face than their chest or genitals. Of participants who have had any procedure (including neurotoxin, fillers, and surgery, but not including laser), the men (n = 55) had mostly chest reductions, as opposed to procedures on their face or genitals. Also in line with their preferences, women (n = 30) reported having more nonlaser facial procedures than those for their chest or genitals (Fig 1). Face procedures Of women who reported having any facial procedure including laser (n = 48), the most common facial procedure was laser hair removal, followed by surgery, then injectables, including neurotoxin and filler (Fig 2). Men reported substantially fewer facial procedures overall (n = 6), including laser hair removal (n = 3), surgery (n = 2), and injectables (n = 1). Of those who had injectables (n = 21), most went to a plastic surgeon (n = 12). Other practitioners who performed these procedures were dermatologists (n = 3), primary care physicians (n = 3), urologists (n = 2), endocrinologists (n = 2), and an ophthalmologist (n = 1). Hormone effects The participants on hormone therapy were asked about the effects of these hormones on specific facial features. For men (n = 118), almost everyone
experienced changes in facial hair, with the next most frequent changes being of the jaw angle, chin shape, and cheek shape, with other features also being affected at a lower rate. For women (n = 71), facial hair was also most frequently affected, with lip fullness and cheek shape following in next highest frequencies (Fig 3, A). Looking at those who have been on hormone therapy for at least 2 years (n = 97), when asked how long it took for the hormones to achieve maximal effect in causing transition-related physical changes, 72% reached this point after 2 years or were still changing, and 14% experienced maximal effect between the first and second year of therapy. These frequencies were similar when broken down by gender (Fig 3, B). Concerns and barriers Participants were asked to select, from a list of possible concerns, which was a major concern, minor concern, or not a concern at all when considering a procedure for transitioning (Fig 4, A). The concern most frequently noted to be a major concern of respondents (n = 226) was that the outcome of the procedure looked good (91%), with the other listed concerns also frequently chosen, which included whether the procedure required surgery, left a scar, had a risk of complications, was permanent, was not permanent, or involved anesthesia. Participants also could write their own concerns, with 1 person expressing concern about the procedure affecting functionality and another questioning whether it would address their underlying dysphoria. From a list of possible barriers, participants most frequently chose money/cost as a major barrier (87%). The other options for major barriers were access to care, having a support system, laws, and stigma (Fig 4, B). Written-in responses included being uninformed and time needed to undergo the procedure. Guidelines Participants (n = 231) were asked whether they thought it necessary to see a mental health professional, be on hormones for 1 year, and/or live as their self-identified gender for 1 year before undergoing facial procedures. This was based on the guidelines of the World Professional Association for Transgender Health, which suggest the above 3 practices as prerequisites for genital reconstruction.20 Before nonpermanent facial procedures, 5% believed that a mental health professional should be seen, 6% thought that one should be on hormones,
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Fig 1. The first body part one would change, if money were not an issue, as compared with body parts already treated with nonlaser procedures (including neurotoxin, filler, and surgery).
Fig 2. Of the women who obtained any procedure on the face, percent who had injectables (neurotoxin or filler), surgery, and/or laser hair removal (LHR).
and 2% believed that the person should live as their self-identified gender. For permanent procedures, these respective percentages were 22%, 23%, and 21%.
DISCUSSION It is often presumed that genital surgery is the primary procedure-related goal of transgender people. In this study, neither men nor women had this as their top priority, choosing their chest or face, respectively, for transitioning procedures. This is potentially because of its implications as a means to pass as one’s self-identified gender in society.21 Testosterone may adequately masculinize a face, but without chest binding or getting a mastectomy, it may be challenging to present oneself as a man. On the contrary, estrogens may help grow breast tissue, but are often not sufficient to feminize a face. Genitalia, regardless of hormonal effects, are not as discernable in public. Of all facial procedures, our female participants are getting laser hair removal the most. It is unclear if this is because of true priorities, or reflects other factors, such as accessibility and cost. What is evident is that estrogen, although effective in removing body hair, frequently does not completely eliminate facial hair, but merely decreases its size and density.4
Therefore, in an effort to either remove the ‘‘5 o’clock shadow’’ or simply the thought of being a woman who shaves her beard, permanent facial epilation can be life changing.22 Women were also undergoing surgical procedures more frequently than receiving injectables for facial transformation. This may be because a permanent outcome is desired, but may reflect a lack of knowledge of options available or rather access to care in the community, among other reasons. Injectables may be a more affordable and accessible option and can give a dramatic and effective result, addressing the largest barrier (money) and concern (outcome) of our participants. However, the transgender community is on average at a lower income level than the general population, as seen in our study sample as well, so injectable procedures may remain cost-prohibitive.23 At this time, although many insurances cover chest/breast and genital reconstruction, facial procedures, both noninvasive and surgical, are considered cosmetic.24 Cost aside, injectables may be the only option for facial modification if the patient is not a surgical candidate or not yet interested in making a permanent change. Individuals may also wish to avoid permanent surgery until they have seen the maximal effect from the hormones. For most of our participants, this happened after 2 years or was ongoing. Aside from hair, men were reporting changes in their cheeks, chin, and jaw, and women in their cheeks and lips, all areas addressable with cosmetic fillers. For those who may ultimately want permanence, injectables may serve as a bridge while hormonal changes take effect, and can also help the patient get an image of how their face could appear before undergoing anything invasive and fixed. Of those who were getting injectables, most sought care from plastic surgeons, likely for varied reasons. They may be already seeing surgeons for other transition-related procedures. Traditional advertising may also contribute to this disparity,
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Fig 3. A, The percent of participants taking hormones who experienced an effect of the hormone on the specific facial feature. B, The amount of time it took until the maximum effect of hormone therapy on physical transformation was experienced (for those on hormones for at least 2 years).
Fig 4. The factors thought to be major concerns (A) and barriers (B) with regard to obtaining a procedure for transitioning.
including several plastic surgeons who specifically market to the transgender population. Plastic surgeons play a critical role in physical transitioning, and are competent in injectable procedures; this merely exposes an opportunity in which dermatologists can also help make a difference. Furthermore, many dermatology practices may not be deemed culturally competent to a transgender patient.3,25,26 Staff should be trained about addressing transgender clientele, including proper use of pronouns and identifiers. Intake forms should be all-inclusive, asking about ‘‘gender’’ rather than ‘‘sex,’’ and leaving a write-in option for ‘‘other.’’ With electronic records, allowing for such versatility will have to be addressed on a larger scale. With greater patient comfort in doctors’ offices, they may be less likely to seek precarious care from nonmedical personnel. Finally, we asked about opinions about possible preprocedure qualifications, as there currently are none established. Although no law dictates what must be done before gender confirmation surgery (chest and genital surgery), the World Professional Association for Transgender Health publishes guidelines that most physicians follow, recommending documented gender dysphoria and, for some
procedures, 1 year of hormone therapy and living as the ultimate gender for 1 year.20 Although they do not propose these guidelines for facial procedures, we were interested in opinions as to if they should. Most individuals believed that these guidelines were not necessary for any type of facial procedure, however of those who did, this was mostly restricted to procedures that were permanent. Our survey is limited in its ability to be generalized to the transgender community as a whole. This generalizability is qualified by the potential convenience sample created by the restricted means of survey distribution, even with the survey reaching 41 states. We had a disproportionately higher percentage of men than women completing the survey. Although there are no clear data about gender breakdown of the US transgender population, Census Bureau analysis of name changes of suspected transgender individuals showed that 65% were by transgender men and 35% by women, providing some insight into the potential distribution within our study.27 The study sample size is also prohibitive, especially in some questions with very low response rates. Furthermore, the survey instrument itself was not formally assessed in terms of reliability and
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validity, using only cross-referencing as a tool to determine if responses were consistent. Nonetheless, the purpose of this study was not to determine exact rates of actions, but rather to investigate need and opportunity for dermatologists to aid in transgender care. Conclusions Aside from case reports of injectable filler use, to our knowledge there has been no clear study of the attitudes and practices of the transgender community with respect to procedural dermatology.17 Our study showed that facial transformation is of high importance in this community, especially for women. Dermatologists have an opportunity to make a difference in this process, providing safe and noninvasive options (including neurotoxin, fillers, and laser hair removal) for facial transformation, in addition to routine and focused medical dermatology. In doing so, our transgender patients may get further alleviation for their gender dysphoria, and like our cis-gender patients (those whose gender identity matches their assigned sex at birth), they may be more comfortable and confident in their appearance. REFERENCES 1. Gates G. How many people are lesbian, gay, bisexual, and transgender? A report of the Williams Institute. Los Angeles (CA): Williams Institute, UCLA School of Law; 2011 2. Steinmetz, K. The transgender tipping point. Time. May 29, 2014: cover. 3. GLAAD. GLAAD media reference guideetransgender issues. 2015. Available from: URL: www.glaad.org/reference/trans gender. Accessed October 2015. 4. Katz KA, Furnish TJ. Dermatology-related epidemiologic and clinical concerns of men who have sex with men, women who have sex with women, and transgender individuals. Arch Dermatol. 2005;141(10):1303-1310. 5. Giltay EJ, Gooren LJ. Effects of sex steroid deprivation/ administration on hair growth and skin sebum production in transsexual males and females. J Clin Endocrinol Metab. 2000; 85(8):2913-2921. 6. Wierckx K, Van de Peer F, Verhaeghe E, et al. Short- and long-term clinical skin effects of testosterone treatment in trans men. J Sex Med. 2014;11(1):222-229. 7. Liguori G, Trombetta C, Bucci S, et al. Condylomata acuminata of the neovagina in a HIV-seropositive male-tofemale transsexual. Urol Int. 2004;73(1):87-88. 8. Wasef W, Sugunendran H, Alawattegama A. Genital warts in a transsexual. Int J STD AIDS. 2005;16(5):388-389. 9. Yang C, Liu S, Xu K, Xiang Q, Yang S, Zhang X. Condylomata gigantea in a male transsexual. Int J STD AIDS. 2009;20(3): 211-212. 10. Fernandes HM, Manolitsas TP, Jobling TW. Carcinoma of the neovagina after male-to-female reassignment. J Low Genit Tract Dis. 2014;18(2):E43-45.
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11. Harder Y, Erni D, Banic A. Squamous cell carcinoma of the penile skin in a neovagina 20 years after male-to-female reassignment. Br J Plast Surg. 2002;55(5):449-451. 12. Centers for Disease Control and Prevention. HIV among transgender people. Atlanta: 2013 Dec. Available from: URL: http:// www.cdc.gov/hiv/risk/transgender/index.html. Accessed October 2015. 13. Zancanaro PC, McGirt LY, Mamelak AJ, Nguyen RH, Martins CR. Cutaneous manifestations of HIV in the era of highly active antiretroviral therapy: an institutional urban clinic experience. J Am Acad Dermatol. 2006;54(4):581-588. 14. Ginsberg, B. Transforming skin: transgender dermatology. Huffington Post. 2013. Available from: URL: http://www. huffingtonpost.com/brian-ginsberg-md/transforming-skin-trans gender-dermatology_b_4122712.html. Accessed October 2015. 15. Altman K. Facial feminization surgery: current state of the art. Int J Oral Maxillofac Surg. 2012;41(8):885-894. 16. Becking AG, Tuinzing DB, Hage JJ, Gooren LJ. Transgender feminization of the facial skeleton. Clin Plast Surg. 2007;34(3): 557-564. 17. Murray R. Transgender woman arrested after injecting Fix-AFlat into patient’s rear end. 2011. Available from: URL: http://www. nydailynews.com/news/crime/transgender-woman-arrestedinjecting-fix-a-flat-patient-rear-article-1.980273. Accessed June 15, 2014. 18. Wilson E, Rapues J, Jin H, Raymond HF. The use and correlates of illicit silicone or ‘‘fillers’’ in a population-based sample of transwomen, San Francisco, 2013. J Sex Med. 2014;11: 1717-1724. 19. Styperek A, Bayers S, Beer M, Beer K. Nonmedical-grade injections of permanent fillers: medical and medicolegal considerations. J Clin Aesthet Dermatol. 2013;6(4):22-29. 20. World Professional Association for Transgender Health. Standards of care for the health of transsexual, transgender and gender nonconforming people. 7th version. 2012. Available from: URL: www.wpath.org. Accessed October 2015. 21. Godfrey C. Transgender men and women discuss the politics of ‘‘passing.’’ Vice Media. March 2015. Available from: URL: www.vice.com/read/passing-when-youre-transgender. Accessed October 2015. 22. James A. Hair removal. Trans road map. 2015. Available from: URL: www.tsroadmap.com/physical/hair. Accessed October 2015. 23. Grant JM, et al. Injustice at every turn: a report of the national transgender discrimination survey. Washington (DC): National Center for Transgender Equality and National Gay and Lesbian Task Force; 2011. 24. Human Rights Campaign. Finding insurance for trans gender-related healthcare. Available from: URL: www.hrc.org/ resources/entry/finding-insurance-for-transgender-relatedhealthcare. Accessed August 2015. 25. Coren JS, Coren CM, Pagliaro SN, Weiss LB. Assessing your office for care of lesbian, gay, bisexual, and transgender patients. Health Care Manag. 2011;30(1):66-70. 26. Robinson A. The transgender patient and your practice: what physicians and staff need to know. J Med Pract Manage. 2010; 25(6):364-367. 27. Cerf Harris B. Likely transgender individuals in US federal administrative records and the 2010 Census. US Census Bureau. 2015. Available from: http://www.census.gov/srd/ carra/15_03_Likely_Transgender_Individuals_in_ARs_and_ 2010Census.pdf. Accessed October 2015.