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Aesthetic Considerations for Treating Lesbian, Gay, and Bisexual Patients: A Review and Our Experience

J Clin Aesthet Dermatol. 2024;17(5):34–39.

by Kerry Hennessy, MD; Steve Dayan, MD; Michael Somenek, MD; Shino Bay, DO; Kristin Witfill, DO; and Sabrina Fabi, MD, FAAD, FAACS

Dr. Hennessy is with University of South Florida Department of Dermatology and Cutaneous Surgery in Tampa, Florida. Dr. Dayan is with the Division of Facial Plastic and Reconstructive Surgery in Department of Otolaryngology at University of Illinois at Chicago in Chicago, Illinois. Dr. Somenek is with Somenek and Pittman MD: Advanced Plastic Surgery in Washington, DC. Dr. Bay is with Shino Bay Cosmetic Dermatology and Laser Institute in Fort Lauderdale, Florida. Dr. Witfill is with HCA Florida Largo at Hospital in Largo, Florida. Dr. Fabi is with Cosmetic Laser Dermatology in San Diego, California

FUNDING: No funding was provided for this article.

DISCLOSURES: Dr. Witfill is a speaker for Galderma. Dr. Somenek is a speaker and investigator for Merz, a speaker, investigator, and consultant for Galderma, a speaker and investigator for Cutera, a consultant for Allergan, and an investigator for Rion. Dr. Fabi is an investigator, speaker, and consultant for Abbvie, Galderma, Merz, Revance, Croma, Endo, and Solta. Dr. Bay is a speaker and trainer for Allergan, Galderma, Merz, Prollenium, Solta, Beneve, DP derm, and Revision.

ABSTRACT: Objective. The population of the United States continues to grow in diversity, particularly within sex and gender. In recent years, there has been a surge in aesthetic procedures in the Lesbian, Gay, Bisexual (LGB) community. Herein, we discuss a tailored approach to these patient populations and offer guidance to address their concerns both safely and effectively based on a comprehensive review of the literature as well as a roundtable series focusing on diversity in aesthetics.

Methods. A literature search was conducted on PubMed using the following terms: “aesthetics,” “cosmetics,” “lesbian,” “gay,” and “bisexual.” Additionally, an eight-part roundtable series focusing on diversity in aesthetics was conducted from August 2021 to August 2022.

Results. The results of the literature search as well as the discussion from the roundtable series addressing the LGB community are reviewed within.

Limitations. We are limited by the paucity of data available in the existing literature. We also acknowledge differences within LGB subgroups and a need for individualization.

Conclusion. A tailored approach to the LGB patient with regard to fillers, neuromodulators, and energy-based devices may offer improved patient satisfaction and safety.

Keywords: LGB, lesbian patient, gay patient, bisexual patient, diversity, aesthetics

Introduction

Each year, the population of the United States (US) continues to grow in diversity, particularly within sex and gender. As of July 2021, the US Census Bureau began to collect information on sexual orientation and gender identity. For the first time, gender identity was addressed asking two questions: “What sex were you assigned at birth, on your original birth certificate?” and “Do you currently describe yourself as male, female, or transgender?”. Additionally, sexual orientation was measured by poll with the following options as answer choices: “bisexual,” “gay or lesbian,” “straight’,” “something else,” and “I don’t know.” Eight percent of the population identified as LGBT,1 representing a doubling of those identifying as LGBT from a decade ago.2 

Unfortunately, there is a paucity of data documenting the number of LGBT patients seeking aesthetic procedures. However, from personal experience of the authors, this population represents a significant proportion of their patient base and continues to grow. The authors emphasize the need to address the aesthetic concerns of LGB patients specifically and robustly. The authors offer their guidance during the roundtable. Please note, a separate roundtable explicitly addressing the transexual community was also held and discussion thereof is currently pending publication.

It is first important to note that many LGB patients have suffered in healthcare and carry prior negative experiences. Studies have found a disproportionate number of LGB individuals do not receive needed medical care compared to non-LGB.3,4 Knowing this, it is vital to create a welcoming environment. The authors suggest establishing rapport with patients by using intake questions that include orientation, gender, and partnership. They emphasize the need to normalize and validate each patient, even suggesting a simple rainbow sticker to demonstrate support. Additionally, not all patients may be “out”, and it is imperative to not make assumptions.

Secondly, one must be aware of preferred semantics. The term “cisgender” denotes when one’s gender identity matches their sex assigned at birth. “Gender fluidity” is defined as a change over time in gender identity with or without a change in expression. Note that not all who change their gender expression or identity identify as gender fluid, nor do all who identify as gender fluid require gender-affirming treatments to change their bodies to fit their gender identity.5

For the aesthetic clinician, individualization of care is paramount, and understanding differences among LGB patients is key for patient satisfaction. Given the lack of data on LGB patients in aesthetics and the need for a tailored approach, the authors address these topics in their roundtable. 

Methods

A literature search was conducted on PubMed using the following terms: “aesthetics,” “cosmetics,” “lesbian,” “gay,” and “bisexual.” We also manually searched review articles for additional studies. Non-English studies were excluded. Additionally, a continuing medical education (CME) event series of roundtable discussions focusing on diversity of ethnicity, sex, and gender was conducted from August 2021 to August 2022. Discussions were held around the world. The LGB series included both providers and patients identifying as LGB.  Leaders in aesthetics, including dermatologists and plastic surgeons, convened to discuss differences and preferences of LGBT patients in non-surgical procedures. The results of the roundtable highlighting the LGB community and a comprehensive review of the literature are discussed within. 

Results

During the roundtable, several important considerations in treating the LGB patient were discussed, allowing for optimization of outcomes and patient satisfaction.  

Social issues. As mentioned previously, LGB patients face significant disparities in healthcare.3,4,6 Increased rates of depression and suicidality are well documented. According to the US Census, 38.2 percent of LGBT respondents experienced depression for more than half the days of the week compared to 16.1 percent of non-LGBT respondents.1 Studies have also found a 3 to 6 times greater risk of suicidality in LGB adults compared to heterosexual adults across all ages and races.7 Aesthetic concerns and psychiatric issues are intimately related as aesthetic providers are well aware. By acknowledging these differences, the clinician may be more fit to diagnose and treat. 

Prescription differences among the LGB community must also be considered. Pre-exposure prophylaxis (PrEP) and highly active antiretroviral therapy (HAART) are more common prescriptions in this group (particularly in men who have sex with men [MSM]) and often carry a stigma. Patients may not feel comfortable disclosing this information. As of 2019, there are an estimated 1,189,700 people with HIV in the US, with 63 percent of those representing gay and bisexual men.8 As providers, it is important to be aware of and comfortable discussing HIV status, as medications prescribed can affect facial volume loss.

An additional health discrepancy LGB patients experience is an increased incidence of eating disorders and a greater risk for the development thereof. A study of 289,024 students from 223 US universities showed increased rates of self-reported eating disorders in LGB students compared to heterosexuals. This rate was notably even higher in the transgender population.9 Along with eating disorders, body dysmorphic disorder may present. According to the OCD & Related Disorders Program at Massachusetts General Hospital, there is a 32 percent prevalence rate of body dissatisfaction among gay men compared to 24 percent, 35 percent, and 38 percent in heterosexual men, lesbians, and heterosexual women respectively. While gay men represent 2 to 4 percent of the US population, they account for 12.5 percent of all men with body dysmorphic disorder.10 Theories behind such discrepancies are addressed with the minority stress model, reasoning that greater stress experienced by LGB persons make them at higher risk for poor mental health and adverse outcomes.11

Expectation management. As with all aesthetic patients, expectation management is key to a productive working relationship. Patients with unrealistic goals will end up dissatisfied and may suffer from body dysmorphic disorder. Prior to embarking on the aesthetic journey, motivations should be explored, and goals should be clearly defined. Provider and patient must come to a mutual understanding, with transparency on the provider’s part being key. In the aesthetic consult, it is recommended to elicit what the patient desires and then for the provider to give their professional feedback. For example, if a male patient comes to consultation requesting bigger lips, it is helpful for the provider to better understand the patient’s goals. If their goal is to feminize, lip augmentation may support this and help the patient express their gender fluidity. 

Most commonly requested procedures. Among LGB patients, requested procedures seem to be notably in line with the rest of the population. As far as injectables, jawline, lips and chin are common areas of focus as they highlight sexually dimorphic features. Advantages of dermal filler include an instantaneous result with no downtime. The primary disadvantage is their transience. Surgical procedure trends include buccal fat reduction, submental liposuction, chin augmentation and rhinoplasty. 

Discussion 

During the roundtable, the authors discussed how to address commonly encountered concerns in LGB patients and methods for injectable use.

Gender-related anatomical differences. When addressing the aesthetics of LGB patients, we must first explore the male and female anatomy. To do so, authors use the neoclassical cannons discussing the face in horizontal thirds. 

Beginning with the upper one-third of the face (Figure 1), males exhibit an M-shaped hairline and convex lateral forehead. They also display supraorbital bossing. Meanwhile, females exhibit a more smooth, contoured hairline as well as smoother curvature to the forehead as visualized from the lateral perspective. Eyebrows in females tend to arch laterally with a positive canthal tilt, whereas males typically show heavier, more horizontally oriented brows and a more neutral canthal tilt. Males also may demonstrate a heavier upper eyelid. 

In the middle third of the face (Figure 2), males display an interzygomatic width that is equal to the mandibular width, creating a squared off appearance. In females, this interzygomatic width extends beyond the mandibular width leading to a more V-shaped, tapered look. 

Similarly, in the lower third of the face (Figure 3), males exhibit a squareness with a strong chin projection noted from the lateral view. The angle of the mandible is also more defined. In contrast, females show a rounder, softer chin.  The cutaneous lip of males is longer compared to females. Male lips (especially upper) also tend to have less volume compared to the female counterpart. As aging occurs, the oribicularis oris muscle and surrounding skin atrophies, leading to a decrease in lip thickness, vermilion lip inversion and perioral wrinkling. Interestingly, these findings seem to have a greater impact on female aesthetics than males. This may explain the sex discrepancy in patients seeking perioral rejuvenation (with women presenting more commonly than men).13,14 

The lesbian patient. When addressing the lesbian cosmetic patient, again, preferred semantics are important. Historical terminology has included “lipstick” and “butch” to refer to the more feminine and masculine counterparts, respectively. Today, however, preferred parallel terms include “femme” and “stud.” The aesthetic industry is seeing increased popularity in all non-surgical and surgical procedures in the lesbian community, but in general, lesbians do not actively seek aesthetic procedures in numbers comparable to the straight female community. Even though we should shy away from categorizing individuals and how they identify themselves, we as aesthetic providers must realize there is a spectrum to how lesbians identify. Those that identify as being more feminine tend to seek aesthetic procedures similar to their straight female counterparts.  In contrast, lesbians who identify as more masculine tend to shy away from aesthetic procedures following the aesthetic trends of the straight male community. 

Authors begin by noting the difficulty in finding a lesbian patient model for the roundtable. Discussion included that there seem to be a dearth of role models and examples of lesbians undergoing cosmetic procedures. Hypothesized reasons for this include cost, a lack of concern for physical appearance, and a lack of desire to conform to traditional societal beauty standards that often prioritize heteronormative beauty ideals. It is important to remember that these are generalizations and there is a wide range of individual differences and motivations for why someone may choose to undergo aesthetic procedures or not. Given the paucity of data specifically addressing aesthetic procedures in the lesbian community, most recommendations for this population are therefore extracted from females in general. 

It has been posited an oval face is ideal for feminine beauty and therefore treatment to support this shape be implemented.15 Other studies have shown that averageness and sexual dimorphism are directly related to female attractiveness.16 Symmetry also seems to play a role although is not absolute.17 Of course, individual preferences must be taken into account when determining treatment plans acknowledging that the ideal may vary from person to person. 

Neuromodulators are one of our first tools to address female facial concerns. Injection of the corrugators and lateral fibers of the orbicularis oculi muscle raise brow position and sharpen the arch.18 Additionally, neuromodulators injected infraorbitally and lateral to the mid pupillary line can widen the eye aperture.19 Conversely, masseter injection can be used to slim the face giving a more heart shaped or oval appearance.18,20

Injectable collagen stimulators too play a robust role in female facial aesthetics. Authors suggest poly-L-lactic acid (PLLA) as a good option for peri or postmenopausal women because of the significant reduction in neocollagenesis at the level of the periosteum and skin during this time. Aging leads to bony resorption, therefore a common area of augmentation is the malar region allowing for a more convex, feminine face. Additionally, as we age, the nasolabial folds become more predominant due to a lack of pyriform support from maxillary inward rotation. Injection of the pyriform can be performed to create a more youthful and less masculine appearance, by supporting the base of the nose.18,21 Figure 4 illustrates a lesbian patient example and highlights several of the ideals discussed above.

The patient is shown before (A) and two weeks after treatment (B) with 0.5cc of non-animal stabilized hyaluronic acid (NASHA, 20mg/mL) gel to the tear troughs, 1cc of hyaluronic acid (HA, 20mg/mL) to the apices of the cheeks as well as the mid chin and 1cc of HA (15mg/mL) to the lips. Additionally, PDO threads were placed in the lateral cheeks and buccal regions to address skin laxity.

Energy-based devices are another efficacious tool to treat the lesbian patient and may be used to diminish photodamage, elicit skin tightening and address pigmentation concerns. These factors all contribute to skin quality which serves as an important marker of internal health and strongly influences perception of attractiveness.22 A more comprehensive discussion of the use of laser therapy in addressing skin quality is out of scope of this article. 

The gay patient. It is important to note that not all gay men undergo cosmetic procedures, and each individual is different. However, there are several factors which may contribute to the higher prevalence of cosmetic procedures among some gay men. Firstly, gay men may face additional pressure to conform to societal beauty standards, particularly in the context of the gay community which has historically placed a strong emphasis on physical appearance. Secondly, the gay community has often faced discrimination and marginalization, which can lead to feelings of insecurity. Lastly, cosmetic procedures have become more accessible and socially acceptable in recent years, leading to an increase in the overall number of individuals, including gay men, seeking these treatments. While data specifically for treatment of the gay patient is lacking, recommendations may be abstracted from treatment of males in general. 

Between 2015 and 2019, there was a 17.8 percent increase in males undergoing botulinum injections.23 Given the increased muscle thickness of males, we know there are differences in appropriate neurotoxin use between males and females, with males requiring significantly more product.24 The most commonly requested target area in males is the lateral canthal lines. A review by Kandhari et al25 investigating optimal dosages of botulinum toxin in the upper third of the male face suggests an average dosage of Onabotulinum A of 10 to 12.5 units per side for canthal rhytides. Additionally, authors note a suggested average injected dosage for the glabella below 30 units (although a wide range of 8-60 units is documented and more specific recommendations are not made) and 10 to 20 units for the frontalis. Notably, filler is also an excellent tool to address the forehead region as depicted in a gay patient example (Figure 5). More studies are needed to evaluate optimal dosages of botulinum in various locations.

The patient is shown before (A) and after treatment (B) with 1cc of hyaluronic acid filler (20mg/mL of HA) hyperdiluted with 0.8cc of lidocaine 1% to the subgaleal space. Injections were made supraperiosteally in a retrograde fashion until the concavity was no longer visualized.

For the gay patient, authors also emphasize that jawline is key. Figure 6 highlights this dictum showing how dermal filler can masculinize the jawline by creating sharper lines. Authors suggest deposition at the gonial angle which will help improve any jowl present and make the gonial angle more acute. Chin augmentation may also be useful. Deep injection primarily into the pogonion can improve projection of the chin with a goal of creating a parallel plane to the lower lip.26 

The patient is shown before (A) and after treatment (B) with three 1.5cc syringes of calcium hydroxylapatite to the jawline and three 1cc syringes of vycross gel to the chin and gonial angle. Additionally, 4 units of onabotulinum toxin A were used to displace the pogonion inferiorly and 40 units were injected into the platysma and depressor anguli oris enhancing jawline definition. 

Regarding energy-based devices, males tend to focus on individual issues like hyperpigmentation or redness as opposed to more comprehensive rejuvenation as requested by females. Additionally, they may be less tolerant of downtime and repeat procedures. In regards to treatment of vessels, it is important to remember that lasers for this indication (including but not limited to 595nm, 755nm or 1,064nm) may lead to hair loss in treated areas.27 

The bisexual patient. Again, there is a lack of data addressing facial aesthetics of the bisexual patient. Recommendations will depend on the patient’s goals and their gender fluidity. 

Conclusion

For the LGB patient, it is important as physicians to recognize and support gender fluidity. By acknowledging differences in the male and female anatomy as well as sexual identification, we may better serve our patients. Injectables are a vital tool in allowing for gender expression and when used in the hands of experts, can be both safe and effective. 

References

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  2. Inc G. U.S. LGBT Identification Steady at 7.2%. GallupCom. 2023 February 22. https://news.gallup.com/poll/470708/lgbt-identification-steady.aspx Accessed August 19, 2023.
  3. Reisner SL, Mateo C, Elliott MN, et al. Analysis of Reported Health Care Use by Sexual Orientation Among Youth. JAMA Netw Open. 2021 October 29;410:e2124647.
  4. Diamant AL, Wold C, Spritzer K, et al. Health behaviors, health status, and access to and use of health care: a population-based study of lesbian, bisexual, and heterosexual women. Arch Fam Med. 2000;910:1043–1051. 
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  8. HIV Among Gay and Bisexual Men in the U.S. | Fact Sheets | Newsroom | NCHHSTP | CDC 2022 October 11. https://www.cdc.gov/nchhstp/newsroom/fact-sheets/hiv/HIV-gay-bisexual-men.html (Accessed August 19, 2023).
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  16. Valenzano DR, Mennucci A, Tartarelli G, et al Shape analysis of female facial attractiveness. Vision Res. 2006 April;468–9:1282–1291.
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  20. Ginsberg BA, Calderon M, Seminara NM, et al. A potential role for the dermatologist in the physical transformation of transgender people: A survey of attitudes and practices within the transgender community. J Am Acad Dermatol. 2016 February 1;742:303–308. 
  21. Wu GT, Wong A, Bloom JD. Injectable Treatments and Nonsurgical Aspects of Gender Affirmation. Facial Plast Surg Clin N Am. 2023 August;313:399–406. 
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