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TransMed

Hairy Subjects

by Sheila Kirk, M.D.
All of us, Female To Male, Male To Female are concerned with hair someplace on our bodies. We want it in certain places but not in others. We want it certain lengths, certain colors and with certain manageability. Some of us can't get what we want; others don't want what they get. It's a wonder that even with all that is possible with medications and surgical procedures that we can't satisfy everyone all of the time. But we can't!

I want to look briefly at various hair-bearing locations and give insight into what is possible for members of our community. Let's start at the top--the Scalp. Both genetic males and genetic females can experience baldness to varying degrees. For the FTM individual it may only be an occurrence once testosterone therapy has been initiated although baldness of a male pattern does take place in about 20 million genetic women in the U.S. even without testosterone therapy.

For those on testosterone the bald pattern resulting with hormones is a male confirmatory marker--but many would like not to have that effect. Some genetic cause is most probably responsible for this difficulty in a great many instances. There are studies reporting the fact that some male populations in the world have no baldness whatever.

One notable study deals with a male population in the Caribbean born with ambiguous genitalia and raised as females until puberty when male genitalia develop, along with deep voices.

It was found that they had genetic absence of an enzyme system that converted testosterone to dihydrotestosterone -- the hormone that attaches to receptors on hair follicles. As a result the hair follicles do not weaken and shrivel as when the enzyme, 5 alpha reductase, is present. Hence, hair is thick, luxuriant and present into old age.

This observation led to discovery of medication that could block the reductase system and thereby allow for the hair follicle to remain intact. One such drug is Finasteride and is marketed as Proscar. It has been developed recently in a pharmaceutical product called Propecia and is about 1/5 the dose of Proscar. Proscar was developed to halt prostate enlargement. In this dosage about 60% of individuals taking it can experience hair growth and very little in the way of side effects. Although for genetic men, libido can lessen and impotence can develop. For genetic women, development of a masculinized foetus in a pregnancy could be a problem. But this is not generally a concern for FTM individuals.

Could either Proscar 5mg or the 1/5 dose of Proscar marketed as Propecia be effective in a feminizing regimen for the MTF individual? That's a question with no answer at this time. Both medications reduce dihydrotestosterone and thereby will affect the reductase system to inhibit hair loss and allow hair follicle regeneration. We know that blood levels of free testosterone will increase by 10% with the lower dose medication Proscar. Will that increase interference with the feminization process? There are no reported studies to give us an answer at this time. We may need to look at testosterone levels in genetic women using Propecia to get a clue, for nothing about genetic males using this medication while using estrogen is known at this time.

Other pharmaceutical approaches resembling this approach are in the making. An example is a cream or lotion applied directly to the scalp that acts in attaching directly to the dihydrotestosterone receptors and functions more efficiently to prevent hair loss.

No one really knows how it works but an old standby, Rogaine, is a liquid placed directly on the balding regions of the scalp. The medication is known as minoxidil and was developed originally as a drug to combat hypertension or blood pressure elevation.

Taken by mouth it can be a problematic drug. If used as a liquid application to the head in small amounts, it can act beneficially in both genetic males and females in limited numbers with no effects to various body systems even though absorbed through the skin. Results are variable but in the early clinical trials, genetic women had better success than genetic males both on investigator and patient evaluations. The product is still available and should be monitored by a physician. Success rates still indicate it is helpful but perhaps only in less than 50% of those who use it and to variable degrees.

There are surgical techniques to be considered and most of the time MTF individuals will be candidates for this approach. Two methods that are in common use are hair follicle grafts and scalp advancement. Hair follicle grafts or plugs always seem to be a little less desirable because the area treated is usually only sparsely filled in by this hair planting procedure. To cover large areas on the scalp, this technique doesn't seem to be feasible.

The more involved and more extensive approach to elimination of baldness will be the advancement of scalp hair to a more forward or anterior position. This can provide a much improved hair line and once again bangs or otherwise styled hair combing can make the hair line very natural and attractive. It has utility also in filling the hair deficits in the temporal areas of the scalp so common to the male. There are clinics everywhere that advertise their techniques and plastic surgeons are very capable and trained in all the surgical methods that exist to solve this problem.

The Face

Hair on the face is primarily a concern for the MTF individual. While many FTM people want to be clean shaven--they still want the option to shave or not. Beards and moustaches are very acceptable to them. It's the MTF who need and want freedom from facial hair and they approach this problem with all degrees of knowledge and energy. Some wax, some pluck or tweeze, some employ self-electrolytic techniques. All these provide only temporary removal of facial hair. For permanent removal, electrolysis is the only proven and acceptable choice.

But just what electrolytic procedure to consider and what therapist to employ? Those decisions can be very hard choices. The discussions and even arguments that have been exchanged over this are noteworthy. In reading the experiences of the therapist and the clients, it may not be easy to make decision. When considering what is available to us, standard techniques and laser techniques, several considerations are important. Standard electrolysis has been with us quite a while--over one hundred years. But it takes time to clear a face of beard with this approach particularly a dark and heavy one. And it can be costly and for many a very painful experience.

But the proof of it's efficiency is definite and real, if the electrologist is capable and experienced. Sometimes that capability is lacking. Sometimes the operator is not skilled in managing the male beard and hair root destruction is not effective. The opposite is equally possible. Destruction can be so enthusiastic that skin tissue is destroyed as well and scar and pitting develop in the healing. So it would seem that the potential problem with standard electrolysis is not in the method but in the therapist. Selection of the right one is paramount.

Laser electrology is still in development and while those using it exclusively are most enthusiastic, not all their clients agree with them--and therapists using standard electrolysis are vigorously opposed. Even the FDA, the Federal Drug Administration, has limited acceptability of the procedures and the machines in current use.

Advantages it would seem center around speed of removal of hair. Several hours of treatment can cover large areas. But permanency seems to be a problem and -- more importantly -- tissue destruction while attempting hair bulb death seems to be a growing concern.

Therapists are generally physicians or very experienced technicians who are supervised by physicians. Accidents still take place even when such skill is employed. It seems that as one reads the literature, which is by and large anecdotal (that not based on control studies but rather on personal experience), the concerns are two-fold: the method used to remove hair as well as the skill of the operator.

Perhaps more time is needed to observe Laser Electrology. There is a saying in medicine not often spoken but certainly known to most physicians; "Be not the first by whom the new is tried nor the last to lay the old aside." A nice, neutral, in the middle of the road position.

The Torso & Extremities

Some genetic males are covered with hair--over their backs, chests and abdomen. And often consider this along with heavy extremity hair as a sign of "real" masculinity. No doubt many FTM individuals feel the same But the amount of chest and leg hair that the FTM person will grow once on testosterone will be directly related to the number of hair follicles that reside in the skin in these regions. Hence, chest hair may be sparse while leg hair may be quite heavy. It's really the "luck of the draw" and one must wait and see how much and where the hair growth will thicken and increase.

Needless to say the MTF person wants none of this and must rely on any and all methods possible to eliminate growth in these regions. Temporary approaches such as waxing, depilatories and shaving are possibilities and electrolysis, both standard and laser techniques, have been utilized with success. The electrolytic process can be long, painful and costly in these areas but rewarding to the persistent. Variable success is realized with hormone therapy in the MTF in lessening and eliminating extremity hair. In the experience of many, use of estrogen and an antiandrogen over a prolonged period of time has considerable success in limiting extremity hair--particularly on the legs.

This is merely an overview of possibilities open to you. however, you have to explore carefully to determine what is best for you and your needs. Interview several surgeons who specialize in hair transplant. Also, interview several electrologists and get an overall view of their techniques and results. In addition, talk to several electrolysis clients (if possible, people in support groups who are being treated by the electrologists you speak with. They can give you fairly accurate evaluations of those hair removal professionals. You shouldn't be treated repeatedly in the same places. Some reoccurrence of hair is to be expected but if too much your therapist is not killing enough hair follicles.

You can expect some help with your medications to either support hair growth or limit it somewhat, depending on what regimen you are involved with and what your capacity is to respond. Approach this aspect of your care with education, a sense of realism and patience.


Sheila Kirk, MD is a Transgender Medicine Specialist, board-certified in Obstetrics and Gynecology and in practice in Pittsburgh, PA. She is on the board of the Harry Benjamin International Gender Dysphoria Association. She is also a well-known author and leading authority on transgendered medical care and research. Dr. Kirk provides international and national consultations and referrals to the TG community and health care professionals who assist in their care.

She can be reached the following ways:

    E-mail: SheilaKirk@aol.com
    Phone: (412) 781-1092 Fax: (412) 781-1096
    mailing address: Sheila Kirk, P.O. Box 38114, Blawnox, Pa 15238-8114


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