Increasing Awareness of Gender-Diverse Patient Concerns in Dermatology

This article was originally published by Dermatology Times^®.

Matthew Mansh, MD, FAAD, is an assistant professor of dermatology at the University of Minnesota and the director of their Dermatology Gender Care Clinic, which is a part of the university’s Comprehensive Gender Care Program.

The Dermatology Gender Care Clinic aims to “provide high-quality, culturally sensitive care to transgender and other gender non-binary individuals. The clinic focuses on the management of cutaneous side effects of gender-affirming hormone therapy, such as acne vulgaris or androgenic alopecia, and offers minimally-invasive gender-affirming procedures, such as laser hair removal (pre-operative preparation for vaginoplasty or phalloplasty, facial removal, etc.) including assistance in obtaining insurance coverage for these procedures,” according to the University of Minnesota’s Department of Dermatology website.

Mansh recently spoke with Dermatology Times^® to discuss the inequities faced by transgender and gender-diverse patient populations in the field of dermatology.

Q: What are some of the biggest challenges faced by transgender patients in dermatology?

A: I think specific to dermatology, probably the 2 factors would be:

1. Finding providers who are experienced and comfortable with treating transgender and gender-diverse patients. I get a lot of patients who have seen other dermatologists who have sometimes had negative experiences, just because the provider didn't really have any knowledge of gender-affirming care, especially if they're managing a disease that may relate to hormone therapy or some of the other procedures that they get. A lot of these patients are always looking for a home in medicine where they can find culturally-sensitive care from a provider.
2. Accessing certain procedures that I think derm[atology] is unique to offer, that relate to gender-affirming care. And so that's things like laser hair removal, some procedures like Botox, neuromodulators, filler, or soft tissue augmentation, and finding providers who are knowledgeable to do it in trans[gender] people or who are, for some services like laser hair removal, are willing to submit to insurance to obtain coverage for it, so that the patients can actually afford to have those procedures.

Q: What are some discrepancies in care faced by trans patients?

A: I think generally, trans people face a lot of broader societal discrimination in medicine and outside of medicine, and I think we're seeing this a lot now on a state-by-state basis in terms of health care coverage for gender-affirming care, particularly among adolescents and youth. There's many states now that are essentially banning things like hormone blockers, or even hormone therapy, for patients who are under a certain age, like 18.

There's also probably a state-by-state difference in a lot of insurance coverage for these gender-affirming procedures, even for adults. Each state has a different Medicaid policy; some states may be very liberal with providing services. I practice in Minnesota where gender-affirming care, hormone therapy, even many procedures like laser hair removal, can get covered through even Medicaid. But there's other states where that care is explicitly prohibited, which I think pretty uniquely affects trans patients, because they already face a lot of societal discrimination in terms of employment, housing discrimination, and these are people who are more likely to be on services like Medicaid.

I think from a broader standpoint, a lot of the disparities relate to health care access, and it unfortunately is way different in different parts of the country. [In] some areas, there's very good access and [in] some areas, there’s very poor access.

And then I think specific to dermatology: just a lack of knowledgeable providers. Even sometimes in big urban centers still, it's so hard to find people who have a background or specific knowledge of it, because these are topics that weren’t really taught in medical school to a lot of providers, or even been a part of like residency training, until recently. And then also, accessing some of those gender-affirming procedures that we offer; a lot of physicians don't even necessarily know how to offer them or even know how to navigate the insurance process for getting coverage for themselves. Some of them just don't offer it to these patients.

Q: Specific to dermatology, how do these disparities and discrepancies harm patients and lead to inequitable care?

A: I think we see in derm a lot of cutaneous effects of hormone therapy; a lot of it's in transmasculine individuals, so you're seeing a lot of acne and androgenetic alopecia.I think particularly for those patients, because some of the symptoms they’re having are related to the treatment that they're receiving, furthering gender-affirming care. And for those specific diseases, many of the treatments we offer also include things that affect hormones. They often have trouble finding providers who are just knowledgeable in how to manage those conditions, with the complexity of the fact that the condition itself is caused by a medication. And you are in this interesting balancing act of balancing the gender-affirming effects of hormone therapy with the negative side effects and trying to find the appropriate treatment plan that sort of respects both those things. I don't think this is something that's really taught well enough in dermatology residency education, so a lot of people even leave training not having really been exposed to how to tackle a lot of these kinds of issues.

Q: Moving forward, what can dermatologists do, or what should they do, to make sure that in their day-to-day, they're ensuring equitable care?

A: I think every provider needs to just increase their own personal knowledge of these issues, and there's always lots of opportunities to do that. There's conferences on this; at the AAD (American Academy of Dermatology) annual meeting, we hold an LGBT health symposium every year that goes over mainly the basics of all these topics, so definitely increasing your knowledge of these issues, just so you're comfortable with the medicine behind it and managing skin diseases in these patients.

I think it's also just creating a welcoming clinical environment, and this kind of starts before the patient even comes to clinic. It's when they're registering: asking questions about their sexual orientation, their gender identity, their sex assigned at birth, and making sure your staff are trained in this, too, because patients aren't interacting just with physicians. They're interacting with their nurses, and the medical assistants, and just the office people on the phone scheduling appointments, and making sure those staff have some sort of basic training in terminology and how to navigate conversations with those populations.

And then those physical facility changes, like considering having gender-neutral bathrooms. Essentially, people feel like it's a welcoming environment. There’s even signs you can put on your office that this is an LGBT-friendly space, so creating a warm and welcoming environment for these patients who I think have traditionally had a very strange relationship with the health care system. And many of them go into every encounter having had many negative prior interactions with other medical institutions and maybe a general distrust of many medical clinics, and knowing you have to maybe even go an extra mile to rebuild that trust in our own health care system or them.

Q: Why is it so important to acknowledge gender identity and sexual orientation in dermatology?

A: I think this information is incredibly important. Whenever you go into the room, there's certain things you may be thinking about, even before you enter the room, that might help guide the way you ask questions to patients, or even the diseases you may be worried they are coming in with. I think everyone thinks about this from the basis of age, and sex, and race, because we know that diseases are different epidemiology; 20-year-olds coming in for a skin cancer check—that's different than an 85-year-old coming in. And it's the same for sexual orientation and gender identity. We know even skin diseases vary in those populations, so sexually transmitted infections like syphilis, HPV virus, warts, are more common in both sexual minorities and gender-diverse individuals.

We published data demonstrating higher rates of skin cancer in gay and bisexual men. We have a paper coming out soon that shows higher rates of eczema in sexual-minority individuals compared to heterosexual, which could relate to a number of things like environmental exposures, smoking, alcohol use, or even where people are distributed in the US: [if] LGBT people are more in urban areas, you have higher prevalence of things like asthma.

Particularly for the transgender patients, we know hormone therapy affects the treatment algorithm for many of the diseases we treat, including acne, androgenic alopecia, among many others. It may also relate specifically to questioning that you may have to do with a patient about reproductive potential: what sort of organs they still have. If you're prescribing Accutane, which is a teratogenic medication, how do you register them in iPLEDGE, or many of the other teratogenic medications we prescribe on a daily basis? Someone's physical outward appearance may not reflect their internal genital organs, reproductive organs, and so you actually need all that information to make targeted recommendations based on sound medical advice, for whatever condition, many of the conditions that we treat, so I kind of use sexual orientation and gender identity [as] basic demographic variables that are on the same level as age, race, and sex, that really just help frame the entire encounter with a patient, so that you can provide culturally competent, but also evidence-based care, that's based on all those sort of individual factors that they go into the room with, that might change your kind of thinking about the disease they're presenting with.

Transgender and gender-diverse patients specifically, there’s a huge need for more dermatologists to be really actively engaged with helping to care for those patients in a culturally competent,evidence-based way. These patients have been largely ignored, from clinical research, epidemiological research, everything we do in medicine, for many years, and we need a lot of champions within our specialty so that we can actually do evidence-based studies to guide appropriate treatment for some of the unique diseases that affect those populations. From a separate standpoint, we need a lot more advocacy in this sort of policy and health insurance. It's sort of a realm, because there's a lot of movement in especially certain geographic areas in the United States, to restrict care for these individuals. We really need to be on the front line of proving the benefits of the care we provide and advocating for policies and insurance coverage for that care.

From just a personal standpoint, for dermatologists who are thinking about making this a focus of their career, it's an incredibly rewarding patient population to care for, because you can actually have a huge, huge effect on their life. Even something as simple [as] helping someone get laser hair removal on their face, or neck, for instance, can be the difference between that person not being able to leave their house every day and go out in public to someone being able to live a normal life. I think the care we can provide can have an amazing benefit to patients, and it's actually very rewarding as a physician. That's why we all went into medicine. I don't think people shouldn't be afraid to dip their toes into really serving this group particularly.