Dermatology needs to re-think the use of gendered language in aesthetics, according to a brief communication published in the January issue of the Journal of Drugs in Dermatology. The authors contend that gendered language can cause upset or offense in patients with nonbinary gender identity or gender dysphoria, and that gender-neutral language can help dermatologists provide better and more consistent care to all patients.
To find out more about the topic and what this means for dermatologists, I interviewed the authors, Marc M. Beuttler, MD, a 4th year dermatology resident at Louisiana State University (LSU) Health Sciences Center in New Orleans, and Jennifer MacGregor, MD, a dermatologist in private practice in New York. Both have been involved in efforts to improve care to sexual minorities. Dr. Beuttler spearheaded the first LGBTQ health disparities symposium at LSU while Dr. MacGregor has lectured on aesthetics in trans and non-binary patients. They first connected in 2019 and were able to meet in 2021 as part of a Women’s Dermatologic Society mentorship award.
Why do you think this article is especially important at this moment in time?
Dr. MacGregor: I think it’s time we stop imposing our views on gender identity and expression onto others. This is especially important for aesthetic physicians to realize! We are here for our patients to support them and help them look and feel better. It’s not necessary or relevant for us to impose traditional “masculine” or “feminine” ideals on our patients. The individual can be the guide and they can tell us what THEY see and what makes them feel better and more comfortable in their own skin.
Dr. Beuttler: More than ever, we see aesthetic dermatology on social media, in the news – it’s everywhere. Patients are exposed to procedures daily and increasingly seek them out. I would like to see dermatologists celebrating real patients, including – and perhaps especially – those who might not fit preconceived categories of male/female beauty. We need patients of all types to know they can come to medical doctors for excellent care – including aesthetics – and still be who they are.
What personal and clinical experiences motivated you to write this article?
Dr. MacGregor: I’ve been practicing aesthetic dermatology for over a decade now in New York City and several trans patients came out to me during that time. As I helped them with their appearance and treated them through different transition journeys, I had several patients share their experiences with me. They took time to share their honest thoughts, experiences (from good to horrific) and the barriers that keep them from great medical and aesthetic care. Through my patients, I realized that there were dermatologists starting to publish some relevant literature, but few-to-no cases or photos illustrating a practical approach or showing examples of aesthetic dermatology procedures in this population. We really needed to focus and reach out to different communities. Patients need to find something they can relate to in order to feel comfortable coming to your practice. I realized we needed more on our website, more in the medical literature, social media and from our industry partners. I made a push to share more on our website and social media, and to publish some images and examples in an effort to reach out to the community. Once people saw information and relatable people sharing their aesthetic journey, more patients reached out and sought my help with their appearance. The “snowball” effect brought more people to my care and more experiences to refine our perspective on how to help. My patients have been generous with their time and honest in sharing their experiences. I’ve realized through my patients that the most important thing we can do as aesthetic providers is elevate the way our patients feel about themselves before, during and after their encounters with us.
Dr. Beuttler: I have cared for several trans patients in New Orleans who waited far too long to seek healthcare, precisely because they didn’t know how to access the system or if they could trust their providers. It’s our responsibility as physicians to bridge this gap. There needs to be more transparency and more conversations. It’s about continuing to learn from our patients and educating each other.
If dermatologists take one step as a result of reading this article, what should it be?
Dr.MacGregor: Check that your facility is inclusive from the website to the intake form to the staff language. Your website needs a symbol, a landing page or something to indicate you are a safe, “friendly” space. Forms need three pieces of information:
- Gender identity
- Sex assigned at birth
- Preferred pronouns
Practice this intake and language, including pronouns, with your staff. Gender neutral pronouns (they/them) should feel comfortable to all in the clinic.
You mention that gendered language can alienate patients who are non-binary and patients with gender dysphoria. How so?
Dr. MacGregor: Doctors should never use gendered language with patients. Let patients direct what appearance feels most comfortable and aligns with their identity.
Dr. Beuttler: Medical visits are highly personal. People are expected to reveal their entire histories and entire bodies to their physician. Starting this relationship off with an assumption defeats the entire purpose of a physician-patient interaction, which should be one built on trust, open patient expression and thoughtful physician listening in order to provide optimal care.
Why do you believe historical terms like “masculine” or “feminine” should not be used to describe features in dermatology?
Dr. MacGregor: Imagine a trans woman comes in and says, “I’ve had facial feminization and want to look even more feminine. What do you think would enhance my appearance? What should I do?” I say, “Tell me what you see?” Looking in the mirror, that trans woman happens to have a naturally wide and strong mandible which she loves and wants to keep. Her version of “feminine” does not include narrowing her jawline (even though a narrower jawline is historically “feminine”). She actually wants to soften and arch her eyebrows and lift/enlarge her lips. Even though this is pretty straightforward, this is a scenario where the patient could have easily been alienated and shut down. If the doctor had just launched into traditional “masculine and feminine” recommendations without talking to her to understand how she sees herself, the result might not be the desired one. By using descriptive, non-judgmental language, the physician and the patient can agree on the aesthetic plan.
You write about providing points of contrast as ways of helping physicians more precisely understand their patients’ goals. Explain what this means.
Dr. MacGregor: An example would be a wide mandible jawline versus a narrow, tapered jawline (perhaps with a more heart-shaped upper face). Or high-arched eyebrows above the bony rim with open and rounded eyes versus low and straight eyebrows with a straighter shape and lower brow/eyelid.
Dr. Beuttler: The point is to describe features concretely without the implications that “masculine” and “feminine” carry. Naming features as masculine or feminine is limiting. It immediately becomes binary, and individual features are not binary. We use contrast as a starting point in the paper to replace what may historically be viewed as masculine or feminine. The difference is description allows for nuance. There is a spectrum between contrasting features, and descriptive language frees physician and patient to understand each other clearly. Description is inherently more medical.
In the article, you assert that providing points of contrast improves care for all patients. How so?
Dr. MacGregor: People need illustrative language to help them express their thoughts on facial aesthetics. This first has to be in neutral terminology that is universal and easy to understand.
How should dermatologists respond if their patients bring up gendered terms like “masculine” and “feminine”?
Dr. MacGregor: This happens all the time. It’s best to reflect back to them what is “traditionally” masculine and feminine then ask what they like or prefer. For example, “Most people consider a higher, more arched eyebrow to be traditionally feminine, but yours is straighter and angled out at the eyebrow tail. Do you want to accentuate and keep your natural shape or try to raise it to more of an arched position?”
Dr. Beuttler: Some patients might be more comfortable with historically gendered terms – and that’s fine. The point is, we let patients guide this language and do not impose on them. Our job as an aesthetic dermatologist is to explore their vision so we can safely and expertly perform specific alterations.
Why do you think that it’s vital for aesthetic dermatologists to be prepared for more patients who are non-binary or patients with gender dysphoria?
Dr. MacGregor: It’s common! Most people are shades of gray with mixed gender identities and expressions. We can’t generalize and pigeonhole people! Ask them what they see and what aesthetic they prefer.
Dr. Beuttler: Exactly!
What do you envision for the future in how dermatologists relate to their aesthetic patients, whether they are gender-conforming or not?
Dr. MacGregor: All people (humans) can benefit from this approach. This was our goal.
Dr. Beuttler: We’re not proposing language for transgender dermatology. We are proposing language to make aesthetic dermatology more accessible, inclusive and medically-sound for all people.
Patient image used with permission from the Journal of Drugs in Dermatology.
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