The NHS defines gender dysphoria as a condition where a person experiences discomfort or distress because there is a mismatch between their biological sex and their gender identity. According to the NHS clinic for gender non-conforming children and young people in the UK, referrals have risen from 77 people during 2009–2010 to 2590 people during 2018–2019 (Tavistock and Portman NHS Foundation Trust, 2019). There continue to be mixed views and opinions towards this rise in people who express gender fluidity or identify as transgender; Camille Paglia, a professor at the University of Arts in Philadelphia, said in a public interview that ‘The transgender definition has become a convenient label for young people who may simply feel alienated culturally for other reasons’ (Miltimore, 2017). However, the American Psychological Assocation states that ‘Transgender persons have been documented in many indigenous, Western, and Eastern cultures and societies from antiquity until the present day’ (2014). Whether agreeing with the latter statement or perhaps feeling that we have cultivated a society with a greater awareness of gender identity issues, there is still a gap in our mentality and this affects our ability to comfortably and sensitively treat transgender patients. One survey discovered that two in five trans people (which equates to 41% of the 871 trans people asked) felt that healthcare providers lacked knowledge and understanding of trans healthcare needs, while this percentage increases to 51% for trans people living in Wales (Stonewall, 2018). Furthermore, 7% advised they had been refused care within the last year (Stonewall, 2018). Many physicians have confirmed that it is through a lack of familiarity with transition care guidelines and knowledge that poses a problem when faced with treating a transgender patient. If transgender care is not yet adequately taught in medical schools, this raises the question of how a similar lack of familiarity when treating trans people in an aesthetic environment can be avoided.
Knowledge encourages understanding
The first step to advocate for a more welcoming and understanding environment for trans people would be introducing some form of gender identity and diversity training, or including some in a mandatory training programme, for clinics that have one. This will educate staff and treating physicians about the transition process and correct terminologies, as well as the struggles commonly faced by trans people. Staff will gain a better comprehension of what trans people or someone struggling with their gender identity may have gone (or be going) through when deciding to transition and, in turn, start seeking treatment from practitioners. Furthermore, it should dispel any prejudice and assist in preventing any staff trying to learn more about gender dysphoria and the transition process from trans patients themselves. It is also advisable to provide training on the side effects of some of the hormones and medications that a patient may be taking and how they interact with treatments practitioners provide. This way, a suitable treatment plan can be better recommended for each patient if any of these side effects occur. For example, in female to male transitions, the increase in the hormone testosterone stimulates sebum production in the skin that can lead to the onset of acne vulgaris which, understandably, would be an additional distress to the patient and may disrupt their initial treatment plan (Table 1).
| Effective treatments | Male to female: oestrogen | Female to male: testosterone |
|---|---|---|
| Laser hair removal (LHR) | Although oestrogen will slow down hair growth, ongoing treatments of LHR will help manage any hair that continues to grow in typical male patterns (such as the beard). Like any cisgender female attending a clinic, LHR may be requested for general unwanted hair. Due to the hormonal changes, treatments needed may exceed the average amount or be ongoing | Testosterone will encourage an increase in hair production in common male areas, but this comes with its own issues (e.g. ingrown hairs and folliculitis). LHR is beneficial in managing ingrown hairs; however, folliculitis would need topical solutions and could interrupt the treatment plan if it is in the treated area. Like any cisgender male attending your clinic, LHR may be requested for general unwanted hair |
| Electrolysis | Like any previous laser patient, a few stubborn hairs may remain and reoccur after their course(s), which would make electrolysis a more suitable option for hair removal moving forward | As mentioned above, testosterone encourages an increase in hair production, so electrolysis can manage the issues that come with this |
| Skin treatments | Oestrogen reduces sebum production, which can cause pruritus and eczematous changes in the skin in more severe cases. Skin will most definitely become drier, so deeper acidic peels should be avoided. Treatments such as hydrafacials can be particularly effective in balancing and hydrating the skin. For severe cases of pruritus or eczema, topical creams may need to be prescribed. If skin in an LHR treatment area is particularly dry, this will obviously delay treatment | Testosterone increases oil production in the skin and can cause outbreaks of spots or, in severe cases, acne vulgaris. Skin peels containing salicylic acid, for example, will be beneficial in helping treat the spots. Laser resurfacing may then be needed to help reduce scarring left behind. If a client does develop acne, they may need to start using topical creams and or medication which again could interrupt other treatments like LHR or skin peels |
| Injectable services | Generally speaking, female faces have flatter foreheads, arched brows, prominent cheekbones and softer features. Lots of clients opt for non-surgical procedures to their face due to the cost implications and downtime of surgery. Specific injectable techniques can help feminise appearances; however, oestrogen will do this too, so patients should take the hormone for a time before opting for injectables, as their needs may change | Patients may wish to utilise filler to create more of a brow bone, for example, as common male features are a heavier brow bone and more angular features. Hormones will help alter facial constitution; however, lots of patients will still opt for facial injectables to achieve a more masculine appearance |
| Body treatments (e.g. cool sculpting) | Oestrogen will help displace fat deposits to a more common female pattern, such as the hips and buttocks. Fat deposits from the stomach area, more common in men, will reduce but may still be apparent and want to be reduced by the patient. Oestrogen will cause the fat to deposit closer to the skin, which can cause the appearance of cellulite. This again may be something that patients will look into treating. Treatments such as cool sculpting could be a useful solution | In the case of female to male transitions, treatments like cool sculpting can be used to help any stubborn fat deposits that remain in normal female areas that the testosterone has not reduced enough or displaced. Areas like the hips, buttocks and thighs are likely to be treated in this case |
Table 1. Common non-invasive treatments for transgender clients, along with additional considerations due to the hormones in both male to female and female to male cases
The UK LGBTQ community is thriving, so it could prove beneficial to make contact with local community organisations. They will be able to provide the necessary support, should questions arise, not only for staff, but for patients as well. No transition is the same, so support groups could prove a valuable wealth of advice and reassurance for your transgender patients that they may not have been aware of before.
Supporting the transition process
The treatments now available for transitioning patients are extensive. For practitioners only providing non-surgical options (e.g. laser hair removal and injectables), it is worth investigating other establishments that offer other services suitable for transgender patients. In this way, practitioners could partner with them on the basis for referrals. A possible avenue to consider would be surgeons who specialise in gender reassignment surgery or specific gender clinics. Not all patients will feel comfortable discussing the next steps of their transition with their treating practitioner. Therefore, it may be a good idea to actively advertise partnerships around clinics, which will allow patients to contact these other avenues for treatment at their own discretion. Depending on the size of the clinic, practitioners may wish to only select one or two of their team to treat transgender patients. These staff members will soon become experienced with the transition process and be able to provide a thorough consultation, as well as a supportive treatment plan for patients, which trans patients may not have previously had. This continuity of practitioners will not only be more likely to put the patient at ease, but it is also an effective measure in safeguarding a potentially vulnerable person. The reason behind this is that there are a lot of different mental health issues associated with gender identity struggles, contributed to by many possible factors.
The impact of mental health
According to the Stonewall survey, 41% of trans people have experienced some form of hate crime within the past 12 months, 28% have been in an abusive relationship and 25% have experienced homelessness at some point in their lives (2018). These are just some examples of situations that could have an impact on a person's mental health, along with their own possible internal battles over their gender incongruence. These could manifest in a multitude of ways which a practitioner can recognise and become equipped to manage and support only through experience. At times, there may also be a certain level of frustration felt by the patient due to the lengthy transition process. Even the duration they need to endure a treatment like laser hair removal before seeing results, paired with the financial stress of having the treatments in the first place, could well add to their frustration. Therefore, chosen therapists would need to be patient, empathetic and discreet.
» A testimonial from a few satisfied trans patients would be a great advertisement for a clinic in the transgender community «
Food for thought
Getting the transgender-friendly message out
As well as advertising any partnership with other establishments that treat transgender patients, it is also beneficial to advertise as a transgender friendly space—perhaps by way of transgender-themed posters and leaflets for clients to peruse or pass on to friends/family at their discretion. It could prove useful to provide an FAQ sheet to accompany a consultation for a new trans patient; this will help eliminate any confusion or anxiety they may feel about discussing their transition, especially if they are in the early stages. A regular review process throughout a course of treatments will ensure trans clients feel supported throughout their treatment programme as their bodies continue to change, or if they experience any unknown effects from their hormone treatment, as discussed in Table 1.
Another consideration could be altering medical record papers to allow for patients to choose which pronoun they prefer to be referred to as; this way, any embarrassing assumptions are avoided. Like all patients who utilise a practitioner's services, some will prefer to remain discreet about what treatments they have done, while others will not mind who knows and will happily complete a case study, including permitting the use of before and after pictures. The same will be true for some trans patients. A testimonial from a few satisfied trans patients would be a great advertisement for a clinic in the transgender community, demonstrating experience to other trans people. It is worth mentioning this in the consultation process to new patients so that practitioners are aware which patients would be happy to be part of a case study.
Moving forward
As seen from the statistics, how gender is perceived is constantly evolving. It is imperative to keep abreast of these changes so patients can be better supported and practitioners can continue making a difference in their lives. Even making a small adjustment, like showing an awareness of different pronouns on medical questionnaires, will make a huge impact on someone visiting a clinic, as it could help them feel accepted. The author hopes this article will assist in advancing transgender care. It is helpful to keep in mind that everyone has a gender identity, transgender or not, and deserves to be treated fairly and respectfully.
When conducting research for this article, the below websites were found to be particularly useful and informative. These include links to online training and community support: