– AAD Reading Room Content
Share on X. Opens in a new tab or window
Share on LinkedIn. Opens in a new tab or window
email article
This Reading Room is a collaboration between MedPage Today® and:
Cyndi Yag-Howard, MD, vividly remembers the first time a patient came to her with gender identity incongruence.
"The patient and their family members had frequented my office for many years, and we had established a strong patient-physician relationship. One day, as I entered the exam room, my patient seemed unusually nervous, as if afraid to tell me what they were about to share. In an almost confessional manner, they revealed, 'I have gender identity disparity. I don't want you to be uncomfortable with it, but I would appreciate it if you would help me by gently feminizing my features.'"
"To help my anatomically male patient transition to her female identity was one of the most rewarding experiences in my career," Yag-Howard said.
Yag-Howard knew that she made an impactful difference in her patient's life from the beginning of the transition process to the maintenance of it today. "It is a process that we have gone through together. Because of it, I have a greater understanding of the many interpersonal and cultural difficulties transgender patients encounter, as well as the many surgical interventions they must endure. Transitioning from one gender identity to another is a lifelong commitment, and I am honored to be a part of my patient's life-altering transition."
While Yag-Howard was more than willing to provide care for this patient, other transgender patients have not found medical care as easy to come by. According to the National Center for Transgender Equality's 2015 U.S. Transgender Survey, transgender adults have "encountered high levels of mistreatment when seeking health care." Among the survey respondents who sought health care, 33% indicated that they had at least one negative experience with a health care provider such as verbal harassment and/or treatment refusals. Additionally, 23% of respondents indicated that they did not seek health care because of the fear that they would be mistreated.
In recent years, however, there has been somewhat of a sea change in transgender health care, says Joshua Safer, MD, president of the U.S. Professional Association for Transgender Health (USPATH) and executive director of the Center for Transgender Medicine and Surgery at Mount Sinai.
"Essentially, in previous decades -- and still in some areas of the country -- there was the view that transgender was a mental health concern. However, we are recognizing there's a substantial biological component in gender identity and for some there's a biological incongruence between someone's gender identity and their visible anatomy. Therefore, what do you do about that disconnect or lack of alignment? Conventional institutions are now interested in learning about this issue."
As the medical profession at large seeks to learn more about transgender patient care, there is a unique role for dermatology when caring for this particular patient population, said Kenneth Katz, MD, MSc, MSCE, co-chair of the Academy's LGBT/Sexual and Gender Minority (SGM) Health expert resource group (ERG) and a dermatologist with Kaiser Permanente in San Francisco. "I think dermatologists play a critical role in caring for transgender patients because many of the health issues that transgender patients face are directly related to dermatology. We are either doing aesthetic procedures that a transgender person wants as part of their gender-affirming transition, or we are managing side effects of gender-affirming treatments."
This piece takes a look at the clinical and cultural considerations when caring for transgender patients, as well as steps for integrating these competencies throughout the specialty, the house of medicine, and the country's health care system overall.
Medical competency
According to a June 2016 report from the UCLA Williams Institute of Law, about 0.6% of adults in the United States (about 1.4 million) identify as transgender. However, Safer predicts that in time the number of transgender patients will increase. "I think we underestimate the number of transgender people who are out there. As we make it safe for people to come forward, we will see more. It's going to take us some time to get to the stage where we have enough trained people nationally to really cover all of their health care needs." Fortunately, many of the conditions and procedures that a transgender patient may seek a dermatologist for are already a part of their clinical acumen.
Hormone supplementation
"Probably the most common issues that I see are issues related to taking testosterone," said Brian Ginsberg, MD, member of the AAD LGBT/SGM Health ERG. Indeed, for assigned-females transitioning to males, testosterone supplementation can increase sebum production.
As a result, "testosterone has a very clear link in causing severe acne as well as male pattern hair loss," said Ginsberg. "Although topical agents and oral antibiotic medications remain first-line treatments for testosterone-induced acne, many transgender men ultimately require isotretinoin."
For the pattern hair loss, "topical minoxidil is a great therapeutic option and has no likely interactions with hormonal treatment." Conversely, for assigned-males transitioning to females, estrogen/antiandrogen supplementation can reduce sebum production. "Estrogen is more likely to have effects on dryness, itchiness, and eczema," said Ginsberg.
Additionally, while testosterone may cause male pattern hair loss, estrogen/antiandrogen supplementation may cause hair loss on the body and face. However, unwanted facial hair may not be completely eliminated -- which may require laser hair removal, topical eflornithine, or electrolysis.
Surgeries
According to a paper that analyzed data from the National Inpatient Sample, the number of gender-affirmation surgeries increased 4-fold from 2000 through 2005 to 2012 through 2014. While a dermatologist may not be involved in the actual surgery, patients may seek dermatologic care before and after the procedure.
"Top surgery involves the enhancement or removal of the breasts of women and men, respectively. Resultant surgical scars, especially after mastectomy, are often so profound and distinct that they hinder the man's ability to 'pass' as their identified gender when topless," said Ginsberg.
Depending on the scar redness, density, and presentation, physicians can consider laser and light treatments and corticosteroid injections. Transgender patients may also undergo genital reconstruction surgeries, known as "bottom surgery" which involves modification of the genitalia: vaginoplasty, phalloplasty, and metoidioplasty.
While dermatologists may not be involved in the actual surgery, patients may come to them for preoperative hair removal. Additionally, Ginsberg notes that external and internal dermatologic conditions can arise, particularly with vaginoplasty -- some cases of condyloma and neovaginal carcinoma have been reported.
Ginsberg cautions, however, that gender affirming surgery "doesn't necessarily increase your risk of any conditions. What's most important is to recognize that common genital skin conditions also occur on transgender patients and there needs to be a comfort in evaluating transgender patients so that potentially life-threatening conditions including malignancy or simply discomfort are addressed."
Facial transformation
While a transgender patient may not visit a dermatologist for hormone supplementation or gender-affirmation surgery, Ginsberg says that dermatologists are uniquely equipped to play a significant role in transgender patients' physical transformation.
"Dermatologists can use what we typically use for rejuvenation to enhance the femininity or masculinity of the face." According to Ginsberg, there are several key differences between the male and female face to consider. "A feminine face has a flatter forehead, arched eyebrows, eyes that are more open, a smaller nose, prominent cheeks, a more obtusely angled jaw, a smaller pointed chin, and fuller lips."
Yag-Howard indicates that there are several non-invasive options for facial transformation. "For instance, with neurotoxins we can arch the eyebrow in a feminine way or relax it in a more masculine way. We can use fillers to add volume to the cheeks and accentuate the Ogie curve in a feminine way, or we can square the jaw in a masculine way."
Yag-Howard also recommends topical medications to enhance eyebrow growth, which is a prominent masculine feature, and uses lasers to improve skin texture and address unwanted hair growth. Overall, while dermatologists may encounter conditions or procedures that stem from the unique experiences of transgender patients, Katz argues that many of the conditions or procedures will not be outside the physician's wheelhouse.
"Transgender people have many of the same health and dermatology-related concerns as non-transgender people," said Katz. "Probably, in most of our practices we're going to be taking care of the same dermatologic issues that any of our other patients have."
Cultural competency
While dermatologists should already be fairly familiar with the clinical needs that a transgender patient might present with, Katz emphasizes that cultural competency of treating transgender patients is an equally important skill.
"We should have the medical competency from our prior training, but the cultural competency of caring for transgender patients can really make a huge difference beyond just knowing the medicine."
In practice
What are some steps a physician can take in their practice to be more culturally sensitive? "I absolutely think that cultural competence in the workplace starts before the patient even makes it into the exam room," Ginsberg said. "It's about proper education of the staff, so they know how to ask the appropriate questions like 'what is your preferred name and pronoun?'"
Ginsberg recommends having this question on intake forms as well. "While a provider may be confident in taking care of these patients, if the patient is turned off before they even see you it already creates a negative experience."
During the visit, Ginsberg stresses that physicians should be comfortable asking questions about gender identity. "If you ask any question in a manner that shows that you care and that it affects their care, it's often appreciated. An appropriate question is literally asking, 'do you have a preferred pronoun' or 'what is your preferred pronoun?'"
Katz adds that it's important to document appropriately and respectfully in medical charting because the patients can access those records. All told, "It's really hard for physicians to be experts in all gender issues," Katz said. "We're probably going to make some mistakes along the way or we might say something that doesn't come out right, but we should try to do everything in a respectful way and ask for more information or help from the patient about addressing certain issues. Respect is really the key to a successful patient encounter."
Education
Outside the walls of a physician's practice, what can be done to improve the medical and cultural competencies of treating transgender patients throughout the specialty and the house of medicine?
"In my view, it's really education," said Safer. "That's a key element: teaching people in medicine -- appropriate to their level, or degree of training, or specialization -- specifically what to do with transgender care. If you teach these issues formally in medical school or during training there's greater credibility for the subject."
As President of USPATH, Safer is heavily focused on educating the medical community about transgender care, and personally developed a pilot program for a transgender medicine elective at Boston University School of Medicine where students rotated on services that provide clinical care for transgender individuals.
"A lot of training up until now has been selling a conventional LGBT framework where you learn about respect and appropriate terminology, but all of that is really just how to be polite to people. That's important but it's not enough. Transgender people actually have medical interventions that they're seeking and you need to be the expert in the room in your specialty at the very least."
Care coordination
In addition to increasing opportunities for hands-on education regarding transgender care, Katz can personally attest to the value of care coordination among various specialists for transgender patients. At Kaiser Permanente, Katz works in an integrated group for transgender care that is made up of primary care, mental health, surgery, social services, nurses, and pharmacy physicians and providers.
"We all collaborate in the care of the patients and it works very well. We all have access to the patient's medical records and information as to gender identity, preferred name and pronouns, and other aspects of the patient's medical history. It makes it a seamless experience for a transgender patient."
For physicians looking to link up with other specialists, Ginsberg recommends asking members of the transgender community. "A lot of transgender individuals seek similar providers and a lot of the providers happen to know each other, so a lot of times asking your patients who else they're seeing is a good way to see what other providers are out there in your community who are comfortable with transgender patients."
Policy changes
While dermatologists can take steps to improve medical and cultural competencies of caring for transgender patients in their practices and specialties and within the house of medicine, there are factors outside of the medical community that are having an impact on dermatologic care for transgender patients. One of Katz's colleagues at Kaiser Permanente was taking care of a transgender man who had severe acne and was a candidate for isotretinoin. However the FDA risk evaluation and mitigation strategies (REMS) program, iPLEDGE, would have required the patient to register as a female of childbearing potential because of his gender at birth.
"For someone who has strong feelings that he is a man, that was a huge barrier for him and too bitter a pill to swallow," Katz said. "That program really prevented his accessing the medicine that he really needed."
Since then, a coalition has assembled calling on the FDA to establish gender-neutral patient categorization in REMS, essentially asking the FDA to focus on reproductive potential as opposed to gender identity with the iPLEDGE program.
"There was an in-person meeting in April 2016 at the FDA headquarters that was attended by dermatologists, transgender health advocates, and academics. The FDA appeared very receptive to understanding the problem and to rectifying it," Katz said. "There was also a first-ever transgender health listening session that was organized by a high-level official at the FDA in January 2017. Kaiser Permanente was represented and I was one of the participants in that session along with other health centers and transgender health advocates. All of the stakeholders mentioned this issue as an important one to be changed by the FDA."
Additionally, at the American Medical Association's (AMA) House of Delegates' 2017 Annual Meeting, the Dermatology Section Council, led by Yag-Howard, successfully introduced a resolution calling on the AMA to work with the FDA to establish a gender-neutral patient categorization in REMS. Similarly, in February, the American Academy of Dermatology Association Board of Directors revised its position statement on isotretinoin to support "a gender-neutral categorization model in iPLEDGE that is based on child-bearing potential and not gender identity."
Given the amount of support for change, Yag-Howard is optimistic that the FDA will update its iPLEDGE categorization model. "I would be surprised if they didn't take action. The AMA is behind it and specialty societies are all behind it. We have a lot of support and it just makes sense."
While Katz contends that there is a need for increased medical and cultural competency when treating transgender patients, ultimately the care that physicians provide simply boils down to the basics of providing quality care for any patient population.
"Transgender people are like other patients and are not necessarily defined by one identity. It's often part of their identity, but they're also a person of a certain age, ethnic background, and socio-economic group living in a certain area. There is a lot of intersectionality with other identities that we as dermatologists need to be aware of to be culturally competent as well as medically competent."
