Hirsutism is known to be a significant source of gender dysphoria in transfeminine individuals, but a qualitative study recently published in JAMA Dermatology sheds new light on their experiences in living with hirsutism and seeking permanent hair removal.

In interviews, 17 transgender women and one nonbinary individual assigned male sex at birth described discrimination, social and romantic isolation, gender dysphoria, and low self-esteem related to hirsutism. Participants in the study also described feeling insecure discussing hirsutism with clinicians and wanting more comprehensive and transfeminine-specific discussions.

“What may be surprising to clinicians is how much this really, really matters to our patients,” senior author Howa Yeung, MD, MSc, associate professor and vice chair for research in the Department of Dermatology at Emory University School of Medicine, Atlanta, said in an interview.

“Many of them reported that because of concern about their hair growth, they avoid specific social situations, they avoid dating and intimacy…. And they plan their lives around management of their hair,” Yeung told Medscape Medical News. “Some even said that if they’re traveling to rural areas or more conservative areas, the visibility of their hair could even [instill] fear for their physical safety.”

Multilevel changes are needed, he and his co-authors wrote, that involve advocating for insurance coverage for permanent hair removal (laser hair removal [LHR] and electrolysis), improving clinician counseling on treatment options, and expanding transgender persons-inclusive hair removal services.

Permanent Hair Removal: Beyond Cosmetic

Study participants — 17 transgender women and one nonbinary individual assigned male sex at birth, with a mean age of 38 years (age range, 22-68 years) — were recruited across three clinical settings in Atlanta. They completed an electronic survey, self-reporting hirsutism severity using the body-neutral and gender-neutral modified Ferriman-Gallwey score, and reporting on quality of life, perceived gender identity congruence, and self-perceived stigma.

Participants then took part in semistructured interviews in which they were asked to describe the impact of hirsutism on their daily life and their experience with hair removal options. The interviews were subjected to thematic analysis.

Most described perceived transphobic reactions to their hirsutism, and in anticipation of transphobia, some wore masks to hide their facial hair. Descriptions of feeling depressed and ashamed of their hair were common, as were descriptions of hair removal routines that could take several hours, the authors reported.

Of the 18 participants, eight reported eventually receiving LHR and four received electrolysis. Cost and lack of insurance coverage were described as major barriers to permanent hair removal, and there was hesitancy expressed about interim hair growth required for permanent hair removal.

In an accompanying editorial, Gabriela Olmedo, MPH, of Creighton University School of Medicine, Omaha, and co-authors Alexandr Trifonov, MBS, and Gwendolyn P. Quinn, PhD, wrote that “for many transfeminine individuals, permanent hair removal is not simply a cosmetic intervention but an important component of psychosocial and physical well-being, gender affirmation, and safety.”

Recognizing permanent hair removal as a “medically necessary component of gender-affirming care is both an important step toward expanding access to care…and a commitment to ensuring that transfeminine individuals can live with dignity, comfort, and the freedom to express their gender,” they wrote.

Feminizing hormone therapy does reduce hair growth, Yeung told Medscape Medical News, “but even on optimal therapy, studies have shown reductions of only about half the hair growth rate.”

Self-reported hirsutism was used as an inclusion criterion because clinician ratings may underestimate perceived severity, particularly if patients have removed hair prior to the visit, the study authors explained.

Fourteen patients in the study self-rated clinically significant hirsutism levels, and only one reported having a diagnosis from a clinician — a discrepancy that “highlights the importance of incorporating patient-reported outcomes alongside physical examination findings,” the authors wrote.

What Dermatologists Can Do

Guidance from the World Professional Association for Transgender Health, which Yeung recommends for US clinicians, recognizes permanent hair removal as medically necessary, given its association with reduced gender dysphoria and psychological distress. One large nationwide survey study of transgender and gender-diverse adults in the US, published in 2021 in JAMA Dermatology, demonstrated significant associations between permanent hair removal and lower risk of mental health outcomes such as severe psychological distress and suicidal ideation.

Most health insurance policies, however, do not cover electrolysis and LHR as part of gender-affirming care “because permanent hair removal is dismissed as not being medically necessary,” Yeung said.

Moreover, LHR does not have a specific Current Procedural Terminology billing code, which presents a systemic barrier to insurance reimbursement. And electrolysis is structurally challenging because it is largely performed by electrologists who rarely are part of dermatology practices and who often struggle with insurance matters, he noted.

“For our patients who have a medical indication, it’s important that we work with each one and their insurance plan to find the best way forward,” he said. “We need to advocate for insurance coverage, and if their plan is refusing coverage, we need to work with our patients individually so they can access affordable out-of-pocket options and get the treatment they need.”

Dermatologists also “need to advertise the fact that we can help. A lot of patients don’t know that dermatologists play a role in hair removal. They might think it’s something they go to a spa for,” Yeung added.

At a conference on dermatologic care for sexual and gender minorities held in June, at George Washington University School of Medicine and Health Sciences, Washington, DC, Pooja Sodha, MD, said LHR is less painful and requires fewer treatments than electrolysis, although “it’s not effective for treating light colored vellus hairs.”

Permanent hair removal, she said, is “the most common gender-affirmative procedure sought by transfeminine people…and cost is the most common barrier.” Sodha is associate professor of dermatology and director of the Center for Laser and Cosmetic Dermatology at George Washington University.

Electrolysis, Yeung and his co-authors noted in their paper, is less expensive per session but requires more sessions and 1-3 days of hair growth beforehand.

Cisgender women with polyendocrine metabolic ovarian syndrome face many of the same psychological consequences of hirsutism and coverage barriers — a fact noted in both the research paper and the editorial.

“Although the underlying causes of hirsutism differ, the shared experiences underscore the profound psychosocial impact that unwanted hair can have across diverse patient populations,” the editorial authors wrote.

The study was supported through aid received by Yeung from the National Institute of Arthritis and Musculoskeletal and Skin Diseases and the Dermatology Foundation.

Yeung reported personal fees from Pfizer, L’Oréal Dermatological Beauty, the American Academy of Dermatology, and Sanofi Genzyme, as well as grants (not related to the study) from several companies and organizations. The editorial authors and Sodha had no disclosures.