Electrolysis in Transsexuals

Second Edition, November 1997




Preface

This booklet was written as a summary of good practice for the electrologist treating male-to-female transsexuals. It is not intended as a detailed introduction to the condition of transsexualism: for such an introduction your attention is drawn to the booklet "Transsexualism: A Primer", available from the Looking Glass Society.

Electrolysis is in some respects more of an art than a science, and so this booklet represents a consensus of opinion based on input from several electrologists who have experience of treating transsexuals, as well as from transsexual women who have undergone electrolysis.



©The Looking Glass Society, 1997.
This booklet may be copied unchanged in its entirety and distributed for any non-commercial purpose promoting the understanding and well-being of transsexual people. Copying outside these terms requires the Society's written permission.

Contents

1  Transsexualism and Gender Reassignment
2  Electrolysis in Transsexuals
    2.1  General
    2.2  Treatment Timescales
    2.3  Which Method?
    2.4  Technique
    2.5  Pain Control
    2.6  After-care
    2.7  Genital Electrolysis
3  Other Epilation Methods
    3.1  Laser Epilation
    3.2  Tweezer Electrolysis
    3.3  Home Electrolysis Kits
    3.4  Radiation Treatment

1   Transsexualism and Gender Reassignment

Transsexualism is a medical condition (a form of Gender Dysphoria ) in which a person is born with their gender, or 'brain sex', opposite to their physical (genital) sex. So a male-to-female transsexual is a person born with a male body but a female brain and hence a female identity. This condition causes a great deal of emotional pain and suffering, and frequently leads to suicide. The only feasible treatment is to modify the person's body to bring it in line with her gender identity and enable her to live in the female role, as it is not possible to alter her 'brain sex'.

Transsexualism is quite different to transvestism and homosexuality, and should not be confused with either. Transvestites are men who dress as women for sexual or emotional relief, but do not have female brains and possess a normal male self-identity, and have no wish to 'change sex'. Gay men and lesbians are attracted to people of their own sex but are normal men or women with no desire to 'change sex'.

For a person diagnosed as transsexual ('TS') by a properly qualified specialist, a process of Gender Reassignment takes place. The steps of the process are:

There are a number of obstacles to a successful gender reassignment, perhaps the greatest being the need to work and function socially as a woman prior to the surgery taking place. The patient must undergo a 'Real Life Test' (RLT), living in the new role for at least a year, to demonstrate her ability to function as a woman, as well as obtaining approval from two specialist psychiatrists.

Hormone therapy is generally started before RLT, as most patients need the changes that hormones give in order to 'pass' in their new role. Male-to-female hormone treatment causes development of breasts, usually rather small, as well as redistribution of body fat and a general feminisation of the figure, hair and skin. Body hair is often reduced but not removed, and hormones seldom have any large effect on facial hair, electrolysis being the only effective method for removing this. Hormones will not alter a male voice (nor will genital surgery), so speech training is also required.

The genital surgery involves removal of the male genitals and the construction of female genitals (excluding uterus and ovaries, of course) using material from the male genitals. Present state-of-the-art surgical technique produces a very good approximation to natural female genitals, with full sexual sensation.

The condition of Transsexualism, and the process of Gender Reassignment, are more fully explained in the booklet "Transsexualism: A Primer" available from the Looking Glass Society.

2   Electrolysis in Transsexuals

2.1   General

Almost invariably, male-to-female transsexuals require electrolysis treatment to remove facial hair, prior to or shortly after their change of gender role. In rare cases this has been obtained on the NHS, but at the present time it is hard to obtain any treatment on the NHS for transsexualism and most clients will pay for electrolysis privately.

The usual standards of good practice, such as sensitivity and confidentiality, apply as strongly to transsexual clients as to any other clients. Transsexuals are often very self-conscious about their facial hair, and indeed about any physical feature that reminds them of their hated masculine past.

A sympathetic and skilled electrologist is in a position to make a very positive contribution to the quality of the client's life, and conversely transsexual clients are usually very co-operative, and punctual for appointments, as the removal of male-type facial hair is so important for them. Furthermore, transsexuals tend to be long-term clients requiring a large amount of treatment, so a willingness to treat them makes 'good business sense'.

2.2   Treatment Timescales

A typical transsexual, who has developed to adulthood with a male body, will have a typical male facial hair pattern and strong, deep-rooted hair. A large amount of treatment will almost inevitably be required, many hundreds of hours spread over a 2--3 year period, is not unusual; up to five years may be required in some cases. Regrowth may be strong and rapid, necessitating a relatively large amount of treatment per week to make any progress: 4 hours per week is not unusual, of which maybe half could be spent on regrowth in the early stages.

Hormone treatment alone does not have a significant effect on facial hair, but coupled with electrolysis it affects the regrowth rate substantially. Transsexual clients who start electrolysis prior to hormones should be advised that progress may be slow until hormones (preferably with antiandrogens) are started. Regrowth rate generally diminishes further once the testes are removed, either as part of Gender Reassignment Surgery (GRS) or in a separate preliminary procedure (Bilateral Orchidectomy).

It has occasionally been suggested that it is necessary for transsexual clients to have their facial hair cleared at least to the point of being able to stop shaving before GRS goes ahead. This is not true: while any transsexual will wish to be cleared as fast as possible, for the majority electrolysis will take longer than the 'Real Life Test' and will continue after GRS, and there is no reason to delay GRS while electrolysis is completed.

Body hair is usually reduced quite significantly by long-term use of feminising hormones, but some transsexuals may still require some body hair to be cleared by electrolysis. This will not be discussed in detail here as the methods are no different from those used on natural-born women; although the hair may well be stronger than in natural-born women and extra care may therefore be required.

2.3   Which Method?

The first question, and one which always raises controversy, is which method of electrolysis to use in a transsexual client: diathermy, or blend (galvanic is just too slow, and flash thermolysis is inadvisable on the face due to the high risk of skin damage).

The best consensus of opinion that the authors were able to obtain (from electrologists experienced with transsexual clients, and from transsexuals themselves) is that in general diathermy produces a quicker result, even taking into account that diathermy may give a higher regrowth rate, but most clients find diathermy more painful than blend, and generally it provokes a greater skin reaction.

Therefore, it is probably best to use diathermy where possible, provided of course that the client can tolerate it. Some clients have been treated with blend on the most sensitive areas (e.g. top lip) and diathermy elsewhere; many have found that with appropriate pain control and after-care they can tolerate treatment entirely by diathermy. Some clients find diathermy too unpleasant and prefer the generally slower but less painful blend method throughout their treatment.

Another criterion may be the presence of badly distorted follicles. Most transsexuals are likely to have shaved regularly for several years (this in itself should not distort follicles), and some will have used more drastic techniques such as plucking, which may well cause distorted follicles. Severely distorted follicles are not amenable to treatment by diathermy, as it is impossible to place the needle tip at the hair root. Blend can be used for affected areas of the face, as the lye produced in this method is able to reach the hair root even if the needle is not.

So, to summarise, a suggested check-list for deciding on the method to use might be as follows:

  1. For any distorted follicles, choose blend.

  2. Otherwise, choose diathermy to begin with.

  3. If the client experiences an unacceptable level of pain or skin reaction, switch to blend for the affected areas.

  4. If the 'kill rate' is abnormally low, it may be worth trying blend instead of diathermy; choose whichever method works better.

2.4   Technique

Great care must be taken in treating transsexuals' facial hair: it will normally be true male-type, deeply-rooted and thick terminal hair. The power levels required to effectively epilate this type of hair will be very much higher than for other clients and care must be taken to avoid skin damage. The skin may be made more vulnerable by the effects of high doses of feminising hormones.

It is also worth noting that male-type 'virgin growth' hairs may have particularly large bulbs, which may produce friction as they slide through the follicle (which is a significantly smaller diameter than the bulb). This can produce an illusion of traction, which in turn can lead to accidental over-treatment. If there is genuine traction, the hair will not move at all and should be re-treated; if it moves a little and then appears to have traction then this suggests that the hair is in fact adequately treated but jamming in the follicle, and it should simply be pulled out.

Care must be taken to avoid overtreating any given area: spacing the treated follicles rather widely may be advisable. A degree of pain and skin irritation is inevitable owing to the power levels required for male-type hair, but careful preparation and after-care can minimise these problems, as described in more detail below. Some clients have reported finding gold-plated needles significantly less painful than stainless steel, presumably due to sensitivity to elements in the steel such as nickel. If a client experiences unusual levels of pain or skin reaction it may be advisable to try a gold-plated needle.

There is no hard-and-fast rule for treating different areas in a particular sequence. It is best to be guided by the client herself: she will probably have a very definite opinion as to which areas of her face are most urgently in need of treatment, and provided that each patch is given an adequate recovery time between treatments, the client's wishes should be followed.

Most clients find the area around the mouth to be the most obtrusive; some also consider the neck a 'priority area' as hair stubble or shaving rash on the neck can be very noticeable. Neck hairs often lie at a very shallow angle to the skin, making probing rather awkward and making a reaction more visible.

It is also worth mentioning the 'sideburns' typical in male facial hair growth. Women have fine hair in this area, similar to scalp hair rather than the thick beard-like terminal hair characteristic of the male. Clearing this area outright gives a result which 'looks wrong', but careful application of electrolysis, accompanied with the effects of the hormones, can actually convert the male-type growth to a good facsimile of the female pattern. The method is as follows: the client must first grow her hair in this area to a length of about 8--10mm. Then for each hair in the sideburn area, look closely at it and determine whether it is a coarse male-type hair or a finer vellus hair. If it is vellus, it should not be treated. If it is a coarse terminal hair, it should be deliberately under-treated: apply rather less power than normal, and remove the hair even if there is traction. The effect of this is to deliberately fail to kill the follicle outright, but to damage and weaken it. Over time, this produces the desired effect.

2.5   Pain Control

Owing to the nature of male-type facial hair, many TS clients find electrolysis an unpleasantly painful process. Protracted sessions (two hours continuous treatment is not unusual) repeated frequently over a period of years can be traumatic for many clients, especially as pain threshold has been found to decrease under hormone treatment, whilst electrolysis without hormone therapy is frequently ineffective. The problem of pain for TS clients undergoing electrolysis should not be underestimated; pain that is severe enough to make the client flinch makes the electrologist's task very difficult and may lead to skin damage if the client cannot avoid moving while the needle is inserted. The pain and its consequent problems can be eased by three possible methods: topical anaesthesia, analgesics and sedatives. Generally these are prescription-only drugs and it will be necessary to liaise with the client's GP to have them prescribed for the client.

Topical anaesthesia is best provided with EMLA Cream 5 %; the 30g surgical pack is recommended as the 5g tubes are inconveniently small. The cream is best applied to the area to be treated at least an hour (some clients require longer) before treatment commences, with reapplication as necessary to maintain a cover of cream until the start of treatment. An 'occlusive dressing', generally a plastic film similar to cling-film, can be used to reduce the amount of cream necessary but is usually inconvenient on the face. Most clients find reapplication of the cream every 20--30 minutes a better method. The cover of cream can be left in place until each patch is due to be worked on, and then cleans off easily with isopropyl alcohol, 'medi-wipes' or similar pre-treatment cleansing method. The anaesthesia typically lasts between half and one hour after the cream is wiped off, then progressively reduces.

The drawback of this method is that EMLA cream has limited penetration into the skin, thus the deeply-rooted hair follicles found early in treatment may be poorly anaesthetised. The cream works better once the original hair has been destroyed, as re-grown hair is finer and shallower. EMLA cream treatment can be supplemented with analgesics or sedatives if required. In really extreme circumstances an injected local anaesthetic (such as xylocaine) may be used, but this will of course pose the logistical problem for the client of having a qualified medical practitioner administer the injection and then travelling to the electrologist before the anaesthesia wears off.

Analgesics such as co-proxamol or dihydrocodeine can be used to supplement the effect of EMLA cream, and should generally be taken around an hour before treatment starts. These are prescription-only drugs; mild 'over-the-counter' analgesics (aspirin, paracetamol, co-codamol, ibuprofen etc.) are generally ineffective. Clients should be made aware that some people become drowsy on such medicines and may be unable to drive.

Sedatives may assist some clients when treating the most painful areas such as the upper lip, simply by improving the client's ability to tolerate pain. Lorazepam (1--2mg) or other benzodiazepines have been found to work well in some clients. It should be stressed that sedatives should only be used when really necessary; also the client must be warned that she will most likely be unfit to drive after taking the sedative. Lorazepam is best taken about one hour before treatment starts.

2.6   After-care

Application of a normal after-care cream is appropriate, typically a witch-hazel based product. Some clients find a subsequent application of calamine lotion beneficial. In many clients this will be all that is required, and any inflammation will be tolerable and will disappear spontaneously after a few days at most, but a few clients experience either severe inflammation and swelling, or skin infections.

Some clients experiencing severe inflammation have found an improvement by taking a non-steroidal anti-inflammatory drug ('NSAID', e.g. Voltarol 50mg) and/or an antihistamine before commencing treatment. Topical antihistamines (e.g. Mepyramine Maleate cream 2 %) may prove useful after treatment. In most clients the inflammation is manageable, but in very rare cases it proves intractable, and the client may have to switch to a different method of electrolysis. Voltarol (diclofenac sodium) is prescription-only but many oral antihistamines (e.g. Dimotapp LA, which also contains a vasoconstrictor) and also mepyramine maleate cream are available over-the-counter. In any case, the client is best advised to discuss choice of medications with her doctor.

Clients prone to skin infections after electrolysis can be given a topical antibiotic cream; Flamazine (silver sulphadiazine in a soothing cream base; prescription-only) has been used to good effect in many clients --- this is intended for treating burns, and is therefore appropriate after electrolysis.

The usual after-care advice to clients should be given (no makeup for 24 hours, do not touch the area, and so on), although a sympathetic electrologist must understand that a transsexual woman will face greater appearance problems than all but the most extremely hirsute natural-born women and may 'bend the rules' somewhat. In particular, advice to a TS woman not to shave the area will very probably not be heeded; instead it is better to advise no shaving for at least 24 hours and then to shave very lightly with an electric razor only (a blade razor will probably tear the small 'pimples' which often appear when such coarse hairs are epilated). Similarly, a blanket ban on makeup will probably be impractical; the client should be advised to leave the area alone for as long as possible and then to use a waxy 'post-electrolysis' cream (e.g. 'Apr ès') under their normal concealer and/or foundation (most transsexuals require rather liberal use of concealer until electrolysis has progressed quite far); a few (usually blonde) transsexual clients may have sufficiently unobtrusive facial hair that a tinted after-care cream might be sufficient.

2.7   Genital Electrolysis

No discussion of electrolysis in the male-to-female transsexual would be complete without some notes on the removal of hair from genital skin prior to gender reassignment surgery (GRS).

This is always a sensitive topic with clients and electrologists alike. Not all electrologists would necessarily feel comfortable treating such an area, and a transsexual client will probably feel intensely embarrassed about merely possessing male genitalia, let alone allowing someone else to see them. However, it must be said that genital electrolysis contributes greatly to a satisfactory outcome of the surgery, and some clients become quite desperate in their search for an electrologist willing to treat this area.

The precise method of surgery used depends upon the surgeon performing the procedure; but all methods of GRS place potentially hair-bearing tissue from the penis and/or scrotum in locations where hair would be undesirable and problematical (inside the vagina, under the clitoral hood, and perhaps inside the labia). For this reason, clients are well advised to seek the advice of their chosen surgeon as to which parts must be epilated, and then to obtain the necessary electrolysis well in advance of surgery (to allow the skin to recover).

Genital electrolysis can be exceedingly painful, and the comments made above regarding pain control and after-care apply to genital sites as well as the face. In addition, it must be emphasised that hygiene before and after treatment is paramount, as there is a high risk of skin infections from genital electrolysis. Some clients report using Betadine liquid to good effect, before and after genital electrolysis.

With genital electrolysis, the technique is a little different from other body areas. The hair is essentially the same type as found in the 'bikini line' area, although the follicles are sometimes surprisingly shallow, particularly on scrotal skin. It is safe to use rather high power levels in this area, to assure completion of epilation prior to GRS (the skin will, of course, be inaccessible post-operatively) --- it is not necessary to totally avoid marking the skin, as the skin will never be visible after GRS. The 'flash thermolysis' method, diathermy at a very high power level and short duration, is highly effective: properly performed, it gives a very low regrowth rate, rapid treatment, and is often less painful than slower methods.

Some electrologists have reported good results with insulated needles, helping to confine the tissue destruction to the deeper parts of the follicle and limiting the risk of scarring from the flash method. Scrotal skin in particular may be difficult to probe: the skin itself is soft, wrinkled and rubbery in texture, and the follicles can be very 'tight' in some clients. Careful attention to stretching the skin around the follicle being treated is essential, and some electrologists find a relatively stiff needle, such as some of the one-piece designs, helpful as it may be necessary to push the needle into the follicle considerably more forcefully than with any other site on the body, and a highly flexible two-piece needle may be prone to bending.

3   Other Epilation Methods

This section describes a variety of methods, other than professional needle electrolysis, which are sometimes tried by transsexuals wishing to remove their facial hair. The consensus of informed opinion is that at present, needle electrolysis is the only technique suitable for permanent removal of facial hair in transsexuals; this section is included for information only, to enable electrologists to give good advice to clients contemplating other methods of epilation.

3.1   Laser Epilation

Two methods of hair removal by laser have recently arrived on the market. Both are new technologies and no long-term data is yet available on their safety and efficacy. Some clients have reported good results, however 'horror stories' also abound, and these treatments must, at present, be regarded as experimental and approached with caution, and treatment provided without proper medical supervision (e.g. at certain private clinics) should be avoided under any circumstances.

The great advantages claimed for laser treatment are its speed, as each discharge of the laser can treat numerous hairs, and the lack of a needle which some clients find painful or disturbing. Some clients have claimed good results with laser epilation of the genitals prior to surgery, and some laser clinics are certainly willing to treat the genital area.

The permanency of laser epilation is uncertain at present; indeed, the US Food and Drug Administration specifically prohibits laser companies from claiming permanency. While this may not be a major problem for facial treatment (re-treatment, or treatment of subsequent regrowth by electrolysis would be possible), it is a cause for concern for genital epilation, as re-treatment of skin that post-operatively forms the interior of the vagina is clearly not possible by any method.

In the 'pure laser method', a wavelength of laser light is chosen that is strongly absorbed by melanin. The reasoning is that melanin should be very much more concentrated in hairs than in skin, so the laser light causes selective heating of the hairs, including the root, to a temperature at which protein coagulation occurs, killing the hair follicle.

The principal problem with this method relates to pigmentation and the distribution of melanin. Some clients with very dark hair and pale skin report good destruction of hair with no skin damage; conversely there have been problems with darker-skinned clients as the melanin in their skin causes a dangerous degree of general heating of the skin, causing scars and possible destruction of sebaceous glands (leading to intractably dry skin); and pale-coloured (or grey) hair contains little or no melanin and therefore cannot be treated effectively by this method.

In the 'dye method', a light-absorbing compound is applied to the face and the surplus is then wiped off. The intention is that some of this compound will remain in the hair follicles, increasing the absorption of laser light. The main problems are that the method is indiscriminate: any pore or indentation in the skin will be filled with the compound and thus heated when the laser is discharged; severe damage to skin has been reported. Furthermore, the compound tends not to penetrate deeply into hair follicles, leading to surface heating which may scar the skin and does little to destroy the hair follicle.

3.2   Tweezer Electrolysis

A variety of variations on this theme have been marketed, and new ones appear each year, accompanied by a great deal of marketing 'hype'. The intention is that current is passed down the hair itself from a tweezer-like electrode, and no needle is used. It can readily be demonstrated from electrical theory and some simple bio-electrical measurements, that it is quite impossible to transfer enough energy into the follicle by this method to destroy it, even at the maximum voltage permitted by law. Clinical trials have supported this conclusion, finding that tweezer electrolysis quite simply amounts to nothing more than plucking the hairs, and is a waste of the client's money.

3.3   Home Electrolysis Kits

These items are widely available on the retail market, and are generally very simple, low-powered, galvanic electrolysis units. In practice the power levels developed are quite insufficient to treat male-type hair, and again these products are quite useless in the treatment of transsexuals. In addition, the needles supplied with these units are generally not disposable, non-sterile, poor quality and excessively large in diameter. In the opinion of the present authors these kits are a recipe for permanent skin damage.

It should be stressed to the client that destroying male-type facial hair without causing skin damage is a skilled and delicate process which should only be entrusted to a reputable electrologist with proper equipment and prior experience of treating transsexual clients.

3.4   Radiation Treatment

There have been attempts in the past to use ionising nuclear radiation to kill hair follicles. This is now regarded as unworkable and unsafe: at a radiation level that is considered adequately safe, epilation is seldom permanent, while radiation of a sufficient intensity to permanently kill facial hair poses an unreasonably high risk of skin cancer in the future.


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