Transgender patients and their access to aesthetic treatments

This article is a mere snapshot of the authors' views, opinions and experiences in working with the transgender community. There is much room here for debate and research, as in many areas of aesthetic practice. However, this is a scope of practice that is emerging in clinics and has a significant impact on not only practices, but also learning curves.

Introduction

As an aesthetic nurse and clinic owner, I have reached out to the transgender community to help me gain an understanding of their needs regarding aesthetics, as this was an area in which I had limited experience. My previous knowledge was from many years ago while working in the NHS. I was given the opportunity to support a young person in their pre-transition days. What struck me at that time were the limitations to access information and services. We struggled with the simplest of tasks, like make-up and hair removal. We also struggled with getting people along their journey to understand and take on some of these issues—it was a very frustrating experience.

With the passing of time and more publicity in this area, and if I dare to say a better understanding of needs, I was under the impression that things had improved. Indeed, they have to some degree, but, in my opinion, we are still on the fringes of understanding, and thus being able to offer an adequate service that supports this group of people.

» We have become acutely aware of the difficulties that transgender people experience in accessing services «

Societal views of the transgender community

‘The word transgender—or trans—is an umbrella term for people whose gender identity is different from the sex assigned to us at birth’ (Stonewall, 2017). Although the word ‘transgender’ and the modern definition of it only came into use in the late 20th century, people who would fit under this definition have existed in every culture throughout recorded history. The Gender Identity Research and Education Society (GIRES) estimates about 1% of the British population are gender non-confirming to some degree (GIRES, 2020).

The practitioner's journey in understanding the trans community

I reached out to the transgender community after reading about their difficulties in accessing hair removal services prior to gender reassignment surgery. My previous experience in the NHS gave me the knowledge that there was a need for this type of care. I visited a transgender group at their meeting point, where I was warmly greeted. It was commented that this was not something they had previously experienced. The evening was hugely rewarding for me and so enlightening, I learnt about pronouns and the impact of their individual trans journeys. I could see the support they gave and received, and I was immensely proud that we were able to look at forming a working relationship. An open evening was later held at my clinic so that the group could feel comfortable in my clinical environment. We were able to discuss treatments and offer patch testing to those who were considering treatment.

It was a success and resulted in patients being able to access local care, rather than the expense of travelling out of area for treatments and the cost of the treatments were offered were much more affordable. I saw this group as an opportunity to do something positive for this community. I suppose the nurse in me wanted to support these people who I felt had had such a struggle to be who they truly were and privileged that I was able to offer support.

Although the word ‘transgender’ and the modern definition of it only came into use in the late 20th century, people who would fit under this definition have existed in every culture throughout recorded history

Since this time, we have been able to assist this group of people in managing their needs and psychologically helping them through their journey. I am acutely aware of the issues that they face in their transition period and have spent many hours talking to these people individually and observing them throughout their journey.

Jack was introduced to me at the first meeting. I have learnt so much from Jack and his peers. I have been fortunate to step out of my comfort zone and am immersed in a group who go through anguish, confusion and stigma on their journey.

Jack has explained some of this to me and has truly helped me to see the side that I as a cisgender person would never understand. To my delight, he agreed to contribute to this article.

Jack's journey

‘I came out as female to male transgender around 7 years ago. During my transition, I have undergone hormone replacement therapy and I have a testosterone injection every 3 months, which I will need for the rest of life. I have also had a double bilateral mastectomy (removal of the breasts). This has left me with an aesthetically pleasing chest, but I am left with two very large scars across my chest, along with various self-harming scars from over the years. I had decided that I wanted to have a functional penis. My surgeon and I decided that I would have ALT phalloplasty (where the surgeon creates a urethra and a phallus from a donor site from my thigh).

Lisa worked tirelessly on the area to make sure it was as hair free as possible. This daunting experience was made easier by Lisa's incredible, caring attitude. My surgeon even commented on how successful the treatment was. This has led me to wanting more treatments from Lisa, like reducing the scarring on my chest.’

A factual piece, but I had been moved by Jack's story in the past. It was an insight into being able to understand a small degree of the difficult transition.

‘For years I had battled with addiction and was incredibly unhappy in every aspect of my life. I had been homeless in and out of jobs and attempted suicide numerous times. I always knew I was different but I couldn't put my finger on it. I had come out as gay but something had to change, I had spent years abusing my body and self-harming. I met someone who was transgender and after talking to them it all started to click into place. I waited over 3 years to get seen by a specialist team in London. During that time, I had to come out to friends, colleagues, family. I had to change my name legally, open a bank account. I was lucky that the majority of people have been accepting; there are a few that have not.

I bound my chest to give me the appearance of a flat chest, I cracked ribs doing this and got diagnosed with Costochondritis which is a painful condition that causes inflammation of the rib cage. I had over 1.7k of tissue removed when I had my mastectomy which has left a large scar across my chest.

Every aspect of my life was Jack, apart from my appearance. I presented as male but had very feminine features due to the lack of testosterone. I would get questioned or dirty looks if I walked into the men's toilet, and one evening I got assaulted by a group of men for using a toilet that they didn't think I should be in. Once I started testosterone the man I was supposed to be slowly made an appearance and my confidence grew more and more.

I'm 7 years into my journey, and I'm now in the final stages of surgery. I'm now in a job that I love, in a stable loving relationship. I haven't self-harmed in five years, and I'm in recovery from alcohol and substance misuse.

I've had to learn to love myself again. Transitioning really did save my life.’

Laser hair removal is a popular treatment for trans patients

Unwrapping the gender terminology

Confusion can arise surrounding the terminology used when discussing gender.

Writing this article has taken the authors on a journey of discovery. There is an abundance of terminology and definitions that are new to both old and young generations. It may be assumed that it is a generational phenomenon and the younger demographic would have a better understanding of these terms. However, my young adult children and their peers struggled with some of the terminology (for example, ‘fluid’, ‘pangender’ and ‘cisgender’. Furthermore, they did not fully understand a person's pronouns, namely why someone would prefer to be referred to as ‘they’. A patient helped me to understand this and suggested that when we see a person in the street and are unsure of their gender, we use the word ‘they’, but stressed that surely we can be called whatever we choose to be called.

However, Jessie, our undergraduate placement student, has also been on a journey.

‘I have been exposed to the LGBT community through media and within personal friendships growing up. However, the research that I have conducted has been enlightening and I feel that I am becoming more open-minded. Both Lisa and I have had many discussions surrounding the transgender community, and every day I am learning more about what it means to be transgender. Of course, I will never fully understand the emotional aspect, as I am a cisgendered female.

Part of our discussions included investigating the different terminology included in the LGBT community, and my role was to decipher what these terms meant. Interestingly, despite being brought up with exposure to the LGBT community, I knew less about terminology compared to Lisa, who has personal experience of working with the transgender community.

Beemyn (2020) complied a list of terminology, which can be seen in Table 1.

At the time of writing, the terminology spectrum is ever-growing, and I find myself learning more and more every day.

Personally, I feel that I am an open-minded person and very accepting of the LGBT community; however, I feel that society as a whole is a long way from fully embracing what it means to be transgender and ensuring that the health needs of the trans community are addressed, just like everyone else. I hope we come to a point in time where the need to ‘come out’ is unnecessary and we can just accept someone for who they are. For example, if someone turns to me and says, ‘I am a transgendered female’, then I will simply reply with ‘okay’, because it is just accepting them for whom they are. As a 20-year-old cisgendered woman, this is my hope for the future.’

Rise in transgender treatment for the community

In recent years, there has been a 240% increase in referrals to gender dysmorphic clinics (Torjesen, 2018). These individuals are starting the journey to access medical support and intervention. For nurses working in the aesthetic industry, these people will undoubtedly be looking to access our services. For the trans community, we have discovered that they are no different. GIRES (2014) states that ‘aesthetic care is last on the list after a long life of appointments, consultations and interventions’. Furthermore, in the UK, transgender patients are waiting up to 2 years for an appointment, while NHS guidelines state that the first appointment for hormone therapy and surgery should be within 18 weeks (BBC, 2016).

We have become acutely aware of the difficulties that transgender people experience in accessing services. For example, gender clinics are not local services for this population, and so the service can be disjointed. Within aesthetic clinics, laser hair removal is a popular treatment for trans patients. Stories exist detailing dedicated clinics for this service being difficult to access due to the location of services—these may be over 50 miles away. There are also concerns surrounding funding as services may be partially funded so that a course of treatment offered may be too short a course and too costly for the patient.

There are also mental health issues in this sector. Previously, I was ignorant to the issues surrounding this patient group. I am learning more every day, and it has become my mission and passion for my clinic to be accessible to the transgender community. I am not an expert by any means, but I am certainly reaching out with a whole lot more credibility. I am privileged to be part of this journey where patients divulge their most personal thoughts and feelings, and allow me to understand the impact and intricacies of their journeys. It is a heartwarming experience.

However, above all, it is about integrity, client confidentiality and trust, so as to uphold the Nursing and Midwifery Council code of practice and give the best possible care. To achieve this, it is surely also about education, so as to enable medical professionals to understand the issues and needs of this client group.

Conclusion

It is worth exploring our own thoughts and opinions on gender and identity so that we can offer transgender individuals the care that we would give anyone else. It is about shaping our practice and identifying their needs. This even includes showing willingness to reach out to this group.

A particular learning experience was in not asking transgender patients their birth name. This is something that trans people have expressed to invalidating and frankly dehumanising. The term for this is ‘deadnaming’. This is defined as ‘the name that a transgender person was given at birth and no longer uses upon transitioning’ (Merriam Webster, 2020) Something that may seem as simple as a name is still a part of their wellbeing and something that we should be considerate of when caring for the community. You would not disregard anyone else's name, so why should this be happening to them?

My experiences have been enlightening and I am grateful for the transgender community for taking me under their wing and sharing their experiences. I am now able to share this knowledge and perhaps enlighten others. I am proud to be in this position, and thank you, Jack—you really are an inspiration.