Welcoming gender-diverse patients in your dermatology practice

With the increasing awareness and recognition of the sexual and gender diverse (SGD) community in the United States comes the need to provide competent, humble, and affirmative health care for these individuals across all areas of medicine, according to experts.

In a recent article in Dermatology Clinics, Julia Gao, MD, of Dartmouth-Hitchcock Medical Center in Lebanon, NH, along with Kanika Kamal, MD, of Harvard University, Boston, and Klint Peebles, MD, a dermatologist with the Kaiser-Permanente Mid-Atlantic Permanente Medical Group in the District of Columbia and suburban Maryland, noted that not only do SGD individuals experience disproportionately higher physical and psychosocial health concerns, but data also show that the SGD population is more likely to lack access to health care and to face discrimination within the health care setting.¹

In recognition of Pride Month and as part of Modern Aesthetics’s ongoing support of inclusivity in dermatology, we interviewed Dr. Peebles, past chair of the American Academy of Dermatology’s Expert Resource Group on LGBTQ/SGM (Lesbian, Gay, Bisexual, Transgender, Queer/Sexual and Gender Minority) Health in Dermatology and a member of the American Medical Association’s LGBTQ Advisory Committee.

Dr. Peebles shared advice for making your practice more welcoming to patients of all gender identities.

How can dermatologists make their practices more welcoming and accommodating to all patients (revised intake forms, restroom options)?

Klint Peebles, MD: An environment of inclusion and belonging is essential in order to facilitate a sense of safety and comfort for those who identify as part of the SGD community. Steps can be taken at every level of the patient experience to create a safe space, and even the seemingly smallest of gestures can have an indelible impact on patients looking to be affirmed in their identities.

Many of these steps have been emphasized for years now: inclusive intake forms, gender-neutral restrooms, and inclusive signage, periodicals, literature, and artwork.

For example, if someone were to take a look around your clinic space, would they see only a single, narrow representation of what a family unit looks like in the pictures and artwork? Are the magazines on the waiting room tables and informational pamphlets inclusive of all people, cultures, and lifestyles? Are patients able to see themselves reflected in the culture of the office? These subtle signs are indeed noticed by patients who are looking to be reassured that they are welcomed and affirmed from the second they step into the clinic space. From a practical standpoint, these signals of safety and inclusion allow patients to feel comfortable disclosing important information about their health and risk factors—information that may directly inform the care that you deliver.

Also, everyone in the office must be trained on matters of cultural humility and respectful, inclusive language. That includes call center staff, schedulers, receptionists, clinical assistants, nurses, technicians, and anyone else who interacts with patients, so they are empowered to respectfully navigate conversations with patients of all backgrounds.

What are some of the barriers to providing gender-affirming care in dermatology, and how might they be overcome?

Dr. Peebles: In addition to greater risk of mental health and mood disorders, including anxiety, depression, substance use, and eating disorders, almost half of transgender people have reported considering or attempting suicide. This staggering statistic is a direct result of SGD people being forced to navigate their lives in spaces in which they are left invisible or fundamentally rejected. SGD individuals also experience higher rates of chronic illness and are less likely to be able to access preventive care services. Transgender people are less likely to be insured than their cisgender peers. Depending on the survey, at least a quarter of SGD people report being discriminated against in the health care setting and in some cases are even denied evidence-based care.

With that in mind, dermatology is no exception in the sense that patients may be hesitant to seek care from physicians who are not clearly indicating a safe space and competency in taking care of SGD individuals. SGD individuals tend to seek care from clinics, programs, institutions, or groups that specifically serve these communities, but specialty care can be more challenging, as dedicated clinics such as those that exist in the primary care setting are rare. As such, patients tend to look for other signals or messaging to indicate the safe, welcoming space where their physician will be knowledgeable and equipped to meet their unique needs.

Dermatologists should also be aware of appropriate terminology and be comfortable using these terms. For instance, terms reflecting gender identity, gender expression, sexual orientation, and sexual behaviors should be understood, and clinicians should be adept at conversing comfortably with such terminology and topics in a non-stigmatizing manner, which includes respecting an individual’s choice of pronouns, or choice not to use pronouns at all.

The reality is that seamlessly incorporating nonbinary pronouns, neopronouns, and even no pronouns at all into one’s conversational repertoire requires intentionality and practice. For example, think about how to write a full clinic note for a patient who does not use pronouns and simply wishes to be referred to by name. Although this may seem superfluous, it is critical to understand that pronouns (or the rejection thereof) take on great meaning to all of us and reflect core aspects of our identity. Even the most well-intentioned among us may find these skills challenging to develop. Familiarity through practice is essential.

Lack of gender identity data collection is a structural barrier to providing gender-affirming care, and although initiatives are underway to address this issue within the specialty and at higher levels, efforts to incorporate such data within an individual’s own institution and research are equally critical.

What are some dermatologic concerns faced by patients who may be undergoing gender transitions, and how can dermatologists optimize care for these patients?

Dr. Peebles: First and foremost, SGD patients are not necessarily coming to dermatology with concerns specific to their gender identity and affirmation journey. We see transgender people presenting for skin checks, psoriasis, drug reactions, viral exanthems, atopic dermatitis, autoimmune diseases, and all other dermatologic conditions.

Don’t assume that every transgender person who presents to your clinic is there for an issue focused on identity or affirmation. However, some of the more common affirmation-related dermatologic concerns include acne and alopecia for SGD people undergoing masculinizing therapy with testosterone; eczema, hirsutism, and pseudofolliculitis for transfeminine individuals, as well as complications related to the use of illicit fillers such as nonmedical-grade silicone.

Also, patients may be interested in the full spectrum of minimally invasive dermatologic interventions that can be used to facilitate gender affirmation, including neurotoxins, soft tissue augmentation, laser hair removal, scar revision, and body contouring, among others.

More research is needed to develop a sufficiently robust evidence base regarding optimal management of dermatologic concerns in the context of gender affirmation. However, the most important point when providing high-quality care is to listen carefully to the patient, understand their unique concerns, and communicate with them in a validating, affirming manner while offering the expert care that any board-certified dermatologist can provide.

There is nothing “magic” about dermatologic care of transgender and SGD individuals. Much of it comes down to simply reframing and personalizing our approach while drawing on the expansive, invaluable knowledge base we already have. Providing quality care in the context of lifelong learning and cultural humility helps all of us learn and grow from the lived experiences of those around us.

1. Gao JL, Kamal K, Peebles K. Equity for sexual and gender diverse persons in medicine and dermatology. Dermatol Clin. 2023 Apr;41(2):299-308. doi: 10.1016/j.det.2022.10.001