During Sophia Hernandez’s transition, her skin underwent a massive change: the content creator and activist stopped growing facial hair and started breaking out non-stop.
“It's been a journey to get my skin to where it is now. When I first started taking [hormones], my skin just went wonky,” Hernandez tells Bustle. “It was hormonal and I was breaking out back to back. It was literally just a painful time because you're lowering the testosterone and raising the estrogen.”
Every skin type typically undergoes an adjustment period after an increase or reduction of hormones, so skin changes are expected when trans patients begin their transition. But these problems aren’t just surface-level issues. A 2019 study shows that skin concerns and diseases often go undiagnosed and unrecognized in trans patients, which will then lead to significant impairment to their quality of life and mental health. It concludes that “greater recognition and implementation of dermatologic care will improve overall clinical outcomes of gender-affirming care” in this community.
Hernandez considers herself lucky to have found a great doctor who was kind and helped her through every step of her transition. (“I loved every moment with [my doctor],” Hernandez says. “She made me feel so comfortable in my skin [and] did not make me feel judged. It was just like talking to a friend.”) Others are oftentimes not as lucky.
“I think someone [who is] 30 or 40 [going through transitioning] might [have] tougher skin, but someone [who is] 18 and just starting out, [when they] hear all these scary medical terms, [they] might stray away from doing what they want to do,” she says.
She credits doctors today for being more aware than before about the language they use, saying her younger friends tell her about their positive experiences in transitioning. While her doctor was great, she says the staff could’ve been more inclusive. There’s still more work to be done when it comes to talking about gender and improving patient care overall.
“I understand [doctors] studied this field [and] I'm very grateful for [them],” she says. “However, [relying on gender stereotypes] is not how you talk to your patient...so let’s be a little bit more mindful of how we talk.”
Hormone Replacement Therapy & Skin Care
Hormone replacement therapy (HRT) causes a lot of changes in the skin. According to Dr. Jennifer MacGregor, a board-certified dermatologist at Union Derm and World Professional Association for Transgender Health, those taking more testosterone mostly deal with acne while those taking more estrogen tend to experience dryness.
MacGregor explains that testosterone therapy causes the skin to produce excess oil which will then cause clogged pores, red bumps, cysts, and scarring. The scalp may even get oilier and can cause dandruff. For those undergoing estrogen therapy, she explains that the first two years can cause the skin to become thinner and drier, and there may also be thinning facial hair and an increase in red spots and pigmentation.
She recommends that those in testosterone therapy wash their hair more often (some might even benefit from washing hair every day to offset the oiliness) and incorporate lightweight moisturizers and sheer sunscreen formulas that won’t clog pores. Any severe acne should be looked at by a dermatologist in case a prescription or stronger treatments are required. If undergoing estrogen therapy, looking at more hydrating and gentle products is beneficial.
“Everyone benefits from antioxidants and sunscreen in the morning and retinoids at night (regardless of gender) but the formula should be tolerable and adjusted to the skin type,” she says. “Depending on the individual skin concern, ingredients to reduce redness — such as niacinamide, azelaic acid, and neurotensin — and pigment brighteners — such as kojic acid, tranexamic acid, and acid arbutin — can also be added.”
But each individual’s HRT journey is different. Esthetician Bryce Anthony notes that skin concerns like post-inflammatory hyperpigmentation are more prominent in trans people of color, while someone on estrogen might see their skin improve. Everyone’s experience, he says, is unique.
“All in all, trans skin is still skin and should be treated as such,” Anthony says. “With the barriers trans people of color already face across many sectors in healthcare, providing free corrective skin services reduces one barrier.”
A Rise In Psychodermatology
More and more clinics want to do more than just treat skin concerns. Brooklyn-based Skin Wins, the first Black-owned psychodermatology clinic in the US, gives patients corrective skin care services as well as psychiatric services.
“Opening a psychodermatology clinic was purely out of my desire to fill a need that I desperately needed years ago when I was struggling with severe anxiety and depression,” says Skin Wins’ owner Lily Njoroge. “My skin suffered tremendously as a result, and subsequently my skin suffering made my anxiety and depression worse. My psychiatrist had to increase my medication dosage and frequency just so I could function on a day-to-day basis.”
Skin conditions may seem trivial when compared to other health concerns, but the two are linked. Studies show that acne, alopecia, atopic dermatitis, and psoriasis can lead to depression and suicidal ideation.
“I simply could not ignore the overwhelming evidence that psychiatric comorbidities are directly tied to skin conditions — even in mild cases. It seems as though a conversation is being had, but no action is being taken to mitigate, treat, and prevent this,” says Njoroge. “This is our goal at Skin Wins.”
“Proper trans health care management can be something as simple as addressing someone by their preferred pronouns and names, which is something many health providers do not do,” adds Anthony. “Skin Wins is changing that to allow for full inclusivity in the skin care and psychiatry fields.”
Making Patient Care More Personal
Using the right pronouns is the first of many steps that can make trans patients feel seen and safe. “Back then [during my transition], I wish there was a little bit more transparency [and] a little bit more of a taught language,” says Hernandez. “Because a lot of people don't understand that when you're trans there is kind of a language you have to use when speaking to other trans people.”
“It is very unknown to a lot of people that your language can offend people, even if you don't really mean it to,” adds Dustin Nowaskie, co-founder and president of OutCare Health. “So saying ‘he or she,’ when describing people [or] saying men and women can be very offensive because there are a lot of people that don't identify as either, or they identify as both.”
Nowaskie emphasizes the importance of making trans patients feel comfortable. He encourages providers to pick up on subtle signs if a patient is in distress (which include timidness, not using much communication during consultations, avoiding eye contact, and overall nervousness) and let their patients know that they are listening.
“The reason why these disparities exist is that we still talk about and view people in a very binary, biased, non-conforming way,” he says. “These disparities aren’t going to resolve overnight. But if we can kind of fix the way we speak and interact with people and appreciate diversity, then hopefully over the years the disparities will improve.”
Gaslighting and refusal of care is another major concern when it comes to trans health management. Njoroge says health care providers need to work on eliminating that entirely.
“Believe trans people when they express their concerns and provide them with the treatment they are seeking if it provides any benefit or relief to them, while explaining all potential side effects and providing support along the way,” she says. “Run tests that they request without making it a daunting and incredibly difficult process for them.”
Trans patients who’ve had negative experiences in the past may not be as open or trusting of new doctors. It’s all about making that personal human connection. “I think I used to incorrectly assume that people would just know I would take great care of them because I am a well-trained physician practicing in New York City,” says MacGregor. “Sadly, many of my patients have told me horror stories of poor care, shaming, dismissal, and worse at the hands of medical professionals they entrusted with their care.”
Finding The Right Resources
One way to find the right inclusive dermatologist or health care provider is through OutCare Health, an online database for LGBTQ+ health care resources. Nowaskie started OutCare after realizing there wasn’t a central source for the LGBTQ+ community to find health care providers to tend to their specific needs. “A lot of things were very antiquated,” he says. “A lot of the topics were very stereotypical and discriminatory, always about HIV and nothing else. At the same time, I could not find a provider that I felt comfortable with, [who] understood me as a person, and what I needed in terms of health care.”
At OutCare, patients can find a directory of inclusive healthcare providers, mentorship, blog posts on trans health topics, academic research, and a series on diversity and intersectionality called “Out Series.”
Each provider listed in its directory, called the Out List, is thoroughly vetted. Providers are found through partnerships with medical institutions, nonprofits, and user recommendations. The providers are then put through training to ensure that everyone staffed at each clinic is proficient in trans patient care.
Most recently, OutCare partnered with skin care brand La Roche Posay to create a training program for practices to learn how to better improve in LGBTQ+ cultural competency and patient interactions. It’s not enough for a dermatologist or any primary health care provider to be trained in proper care. Everyone on staff at the clinic — from the nurses to the receptionists — should be trained as well.
“We really bring everyone together: providers, students, community members, patients, people in big organizations ballooned to come together and say, ‘Hey, this is an issue. How can we solve it together?’” he says.
Hernandez encourages any transgender patient to read the reviews on doctors before booking an appointment. Making sure that doctors have experience in treating trans patients and that patients feel safe and comfortable with these providers will help those in their transition. “Find what works for you [and] just do your research,” she says.