“That Guy Kas”: In the Skin of A “Trans* Dude”

I’m following the amazing blog “That Guy Kas: Adventures of a Trans* Dude.” On the blog, Bennett Kaspar, who is (as far as I know) the only person I personally know who is transgender, seeks to “elaborate on [his] transition, muse about life, and point out some of the really weird shit that happens when people think you’re a man.” So what about his skin?

The Social Significance of the Skin We’re In

Like any species, our outer appearance plays a large role in defining us (or how others define us). Strangers identify us as male or female by our skin (and hair), and the majority of us self-identify with our appearance. I feel feminine and my appearance matches and makes sense to me. But for a transgender individual, the skin in which he or she is born does not necessarily define him or her. He or she typically doesn’t self-identify with his or her body and may feel trapped by his or her appearance.

The notion of markedly changing his or her appearance and identity to the rest of the world, thereby revealing his or her true self, may seem like an insurmountable feat. For a growing number transgender people, doing so is absolutely critical. But even this defies convention, as some trans persons don’t feel like they’re in the wrong body. In his blog, Bennett discusses that the trans* umbrella is wide, deserving a broad and thoughtful lens.

I wanted to know more. Not surprisingly, I read that the dichotomy between how one appears and the gender with which one identifies interrupts a transgender individual’s self-harmony. Even during and post-transition from female to male (“FTM” or “transgender man/male”) or male to female (“MTF” or  “transgender woman/female”), which enhances one’s sense of normalcy, one’s skin and hair may continue be a source of heartache and strain. And yet, the skincare changes and needs of transgender persons is only starting to appear in academic literature and subsequently in routine practice.

How can that be? It’s a no-brainer that we should address skincare demands, both medically and aesthetically, in the trans community, particularly if skin so heavily impacts one’s well-being and adjustment to a new, external identity. Trans* persons have been ignored, ostracized, and mocked, leading to silent and secretive lives. Imagine how acutely sensitive a physical exam or discussion about medical/aesthetic needs can be for a trans* person, particularly in this era of insensitivity, ignorance, and lack of awareness. Social acceptance and recognition of trans* persons has come at a shamefully slow pace. In almost six years of practice, I recall treating just one transgender individual, who underwent a MTF transition.

Skin During Transition

So what happens to the skin? Physical transformation usually starts with hormonal intervention. Studies of hormones used in transgender individuals reveal potential skin-related side effects, which ultimately may result in longterm management by a dermatologist or plastic surgeon. For FTM, testosterone may create an oilier canvas with resultant acne and/or seborrhea (a dandruff-like skin condition with redness and scaling). For MTF, estrogens may lead to dryness with resultant eczema (a chronic itchy rash) and body hair loss. In addition, while testosterone causes the growth of often-desired additional hair for transgender men, it may be insufficient. In contrast, estrogen may induce unwanted facial hair for transgender women and the desired body hair loss is often insufficient.

While hormonal management induces skin, as well as voice and even emotional changes, surgical procedures are currently the primary methods for body transformation. Noninvasive body contouring options for fat and cellulite reduction, which may create a more feminine figure, and filler injections, also exist. Breast and genital reconstruction continue to be an impressive and effective way of altering one’s physicality, but it can cause significant and often symnptomatic post-operative scarring that requires extensive medical attention. Here is a bit more detail on surgical and non-surgical interventions.

Bennett’s Skin

Nothing beats firsthand knowledge.  Thankfully, Bennett was willing to candidly answer questions I had on the derm aspects of his FTM transition.

His Milestones:

• August 15, 2015 marked his one-year anniversary on testosterone therapy.
• “Top surgery” was performed on July 8, 2015.

Me: What’s the premise of your new, legal name?

Bennett: “My first name was my last name before, and I took my grandmother’s last name as my new last name. I had been going by Bennett for about a decade so it wasn’t much of a switch.”

What was your skincare regimen prior to hormonal therapy? What does your therapy consist of (e.g., only testosterone)?

“Prior to hormone therapy, my skin care regimen was pretty spotty, at best. I had some basic Neutrogena face wash that I would use when I felt like it, which was about once a week. I did use a moisturizer with SPF 30 in it (Kiehl’s) because I am very sensitive to the sun and I am adverse to wrinkles, but I have to say that I am pretty blessed with very good skin. Super low maintenance and I’ve never had any problems with acne or anything like that. I am only on testosterone and supplements. I take 0.5 cc of testosterone via intramuscular injection (gluteal) once a week. I also take vitamin D, vitamin E, and biotin, in addition to a multi-vitamin.”

Left: One year ago. Right: Current.

How would you describe your skin pre-hormones: oily; acne-prone; blemish-free; or dry?

“Blemish free! Occasionally a little dry in winter, but overall I have been without skin problems all my adult life.”

Since starting testosterone, what skin changes have you noticed, if any? Increased acne; increased oiliness; thickening of facial skin; more ingrown hairs due to facial hair growth; or none?

“I have noticed all of the above, but in very small amounts relative to what I have seen in other trans guys. I occasionally get acne on my chin, where I am growing facial hair, and on my neck. I have increased oiliness (and I am sweating a TON more), so I wash my face at least once a day if not twice a day now (Kiehls men’s face wash). I have also notice my face getting, as you have phrased it, thicker. I’d like to think it makes me look more rugged. 🙂 I have noticed, as I have lost a lot of body fat, that the skin around my forehead seems thinner than it used to be, and I can see veins in my forehead that I could not see previously. I am not sure if I have had ingrown hairs or not, but I try to be diligent about scrubbing my beard and keeping it groomed (still figuring all that out).”

Did any of your providers discuss potential skin/hair/nail changes with you pre-treatment? Did you have any expectations of potential changes?

“All of my doctors have been good about telling me the potential changes, but my best resource has been in other trans guys who have gone before me. I have expected all of what has happened thus far.”

Has your skincare regimen changed, if at all? What products do you use, if any? Have you consulted with a dermatology provider ever/since?

“I haven’t consulted with a dermatologist yet, as my skincare products seem to be doing the trick.”

“Here’s a link to the face wash and moisturizer I love.”

How about changes to your hair and nails? (besides increased facial hair growth. For ex., hair growth in other areas; irritation from hair growth; increased/decreased hair thickness on scalp/arms/legs; or nail changes?)

“I have been losing hair on my head and have gained it everywhere else! No irritation to speak of. I am not balding, per se, but I have noticed my hair line has receded a bit and overall my hair on my head is thinner, which is not bad for me because I have wicked thick hair! My arm/leg hair has thickened but is still blonde. My body hair has increased (although I’m still fairly hairless, but I’m also only 11 months in…) and is reddish in color, which has been interesting to see. I take biotin to keep my head hair thick and to increase my beard growth, so my nails and such have been good as well.”

How many days out of surgery are you? Are the stitches out?

“I didn’t even have stitches! Some sort of dermabond, I think. Tomorrow is two weeks out.”

How would you characterize your scars?

“Scars are small but deep. The doctor says that when they’re all healed they will blend in with my areola and will not even be noticeable. They’re still scabby so I can’t really tell what’s going on, and I have no feeling still, so I can’t really tell how they feel either. Will have to update you on that.”

Have your scars healed well? Any keloids (thick, itchy or painful scars)? Any dehiscence (opening of surgical site(s))?

“None!”

Did your surgeon (or any of the medical staff) discuss scar treatment with you? (e.g., Mederma, massage, baby oil, or Vitamin E)

“I have been using arnica gel on my bruising and taking vitamin E for healing. Because I had peri-areolar surgery (rather than the double-incision “DI” style), my scars are pretty small and don’t need lots of scar care the way DI patients’ do.”