Understanding the needs of gender-diverse patients and patients receiving gender-affirming hormones is crucial to equitable care and properly addressing patients' needs.
A recent study explored the important relationship between dermatologic care and the support and inclusivity of transgender and gender-diverse (TGD) patients, noting that dermatology clinicians play a crucial role in equitable care of this patient population.
The study, published in the Australasian Journal of Dermatology, sought to review the unique needs of TGD patients in Australian dermatology, considerations and best practices for dermatologic care and management, and the importance of providing gender-affirming care.
Study authors Gu et al began by establishing the innate disparities and barriers to care faced by TGD patients around the world, with a particular focus in Australia. More than 28% of Australian TGD individuals have reported experiencing discrimination in a medical setting, they noted. Medical specialities such as dermatology and endocrinology, in particular, play a large role in providing gender-affirming care for TGD patients, notably with care of the hair and skin.
It is first important to establish that the use of preferred names and pronouns, as well as an in-depth understanding of various TGD-supportive terms, can positively contribute to gender affirmation and support a positive patient relationship, Gu et al noted.
Frequently-used terminology may include descriptors of gender identity, expression, and diversity; sex assigned at birth; gender dysphoria and affirmation; and distinctions between social and medical transition.
"While their preferred name and pronoun may well differ from what was assigned to them at birth, this should be highlighted in electronic medical records," according to the authors. "This involves ensuring that clerical, reception, nursing, allied health, and medical staff are all aware of the patient's name to avoid misgendering."
As mentioned earlier in the study, the health care of TGD patients is often best executed with a multidisciplinary approach. Dermatologists, though an important part of the health and gender-affirming care of TGD patients, are one part of a larger care team.
It is crucial to consider whether a patient is receiving gender-affirming hormones (GAH) at the time of treatment, as these may have several relevant physiological effects, often further differentiated by type of hormone therapy.
In the case of feminizing hormone therapies (oestradiol, antiandrogens), dermatologists may see TGD patients present with softening of skin and/or increased skin oiliness, decreased terminal hair growth, and scalp hair changes.
In TGD patients receiving masculinizing hormone therapies (testosterone), dermatologic effects of hormone therapy may include skin oiliness and acne, facial and body hair growth, and scalp hair loss.
Another consideration for dermatology clinicians may be the delivery of GAH, which are often administered orally, transdermally with a gel or patch, intramuscular via injection, or as a subcutaenous implant, in some cases.
"It has been demonstrated within the Australian literature that poor experiences with healthcare environments are correlated to poorer mental health outcomes for TGD individuals," study authors wrote.
Provider knowledge and understanding is a crucial step in creating a care environment equipped to provide equitable care, according to the study.
In settings of clinical examination, the Australian Professional Association for Trans Health, also known as AusPATH, has established a set of guidelines recommending a trauma-informed approach to care in TGD patients. This can include additional considerations and acknowledgements of cultural and gender historical issues, as well as heightened sensitivity and transparency of care.
Testerone therapy in TGD patients often involves care and management of acne vulgaris and androgenetic alopecia, the study noted.
"A retrospective comparative cohort study of 46,507 TGD and cisgender adults demonstrated that the incidence of acne in TGD patients receiving masculinising GAH was 2.4 times higher than in cisgender women and 4.1 times higher than in cisgender men," study authors wrote. "A retrospective cohort of 988 transgender adults found that the prevalence of acne increased from 6.3% to 31.1% following the initiation of masculinising GAH."
Additionally, feminizing GAH may increase a patients' predisposition to xerosis, an important consideration before commencing treatment for acne vulgaris, a worsening concern among patients receiving feminizing GAH.
Chest binding in transmasculine patients may lead to acne, pain, pruritus, infection, contact dermatitis, scarring, and miliaria, for example.
When considering care of TGD patients, dermatology providers should discuss the effects of combined oral contraceptive pills for acne treatment, particularly with potentially dysphoric effects such as menstrual suppression, breast tenderness, or menstrual spotting.
While isotretinoin has been found to be safe in TGD individuals receiving hormone therapy, for example, study authors note that managing acne with tetracyclines in patients also receiving testosterone therapy calls for frequent liver monitoring due to a risk of hepatotoxicity.
Spironolactone, often used as a part of feminizing GAH, may be an efficacious treatment consideration for TGD patients with acne vulgaris. Recalcitrant acne observed in TGD patients actively receiving feminizing GAH may also warrant endocrine evaluation, the study noted.
Additionally, TGD patients receiving feminizing GAH may also face hair-related concerns such as persistent hirsutism and androgenetic alopecia.
"A survey demonstrated that 85% of transwomen desired hair removal, with 94% indicating the face as the indicated site of excess hair," authors wrote. "Gender-affirming hair removal may be associated with improved mental health outcomes and well-being."
Study authors discussed the role of working closely with gender care providers when it comes to managing acne or androgenetic alopecia with spironolactone.
"Dermatologists should prescribe and manage spironolactone treatment in partnership with gender care providers to balance optimal dosages for both acne and gender affirmation while minimizing adverse effects," study authors wrote.
"The provision of quality care in TGD patients is multidisciplinary and dermatologists play a crucial role in providing supportive and inclusive care. Understanding the unique dermatological needs of TGD individuals, including the effects of GAH therapy on skin health is essential for effective management," according to the study. "By fostering a safe and respectful environment, Australian dermatologists may contribute to the improved health outcomes of TGD patients."
Gu Y, Tang GT, Cheung AS, Sebaratnam DF. Dermatological considerations for transgender and gender diverse patients: An Australian perspective. Australasian J Dermatol. Published online November 2, 2023. doi:10.1111/ajd.14179