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, the patient being referred to a Dermatologist for treatment. However, the majority of patients will find it necessary to purchase private treatment.
There are three recognised methods of electrolysis: Galvanic, Shortwave Diathermy, and Blend (a mixture of Galvanic and Diathermy). Each method has advantages and disadvantages; Galvanic is very seldom used today, but some patients find Diathermy preferable to Blend, others find the opposite. Diathermy frequently gives a quicker result, but some patients find their skin reacts too badly to it, and a patient experiencing slow progress or adverse skin reaction would be best advised to try the other method, or a different electrologist.
Patients should be advised to find an electrologist who has a recognised qualification and, more importantly, one who has proven competence in treating transsexual patients: electrolysis of facial hair, particularly in a phenotypic male, is a delicate and skilled process if the skin is not to be permanently damaged.
Owing to the nature of male-type facial hair, many TS patients 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 patients, 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 patients undergoing electrolysis should not be underestimated; pain that is severe enough to make the patient flinch makes the electrologist's task very difficult and may lead to skin damage if the patient 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.
Topical anaesthesia is best provided by prescribing EMLA Cream 5 %for the patient; the 30g surgical pack is recommended. The cream is best applied to the area to be treated at least an hour (some patients require longer) before treatment commences, with reapplication as necessary to maintain a cover of cream until the start of treatment. An occlusive dressing can be used to reduce the amount of cream necessary but is usually inconvenient on the face.
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 patient of having a qualified person 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.
Sedatives may assist some patients when treating the most painful areas such as the upper lip, simply by improving the patient's ability to tolerate pain. Lorazepam (1--2mg) or other benzodiazepines have been found to work well in some patients. It should be stressed that sedatives should only be used when really necessary; also the patient 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.
Any competent electrologist will provide the patient with a suitable soothing and antiseptic after-care cream, typically witch-hazel based. Some patients find a subsequent application of calamine lotion beneficial. In the majority of patients this will be all that is required, and any inflammation will be mild and transient, but a few patients experience either severe inflammation and swelling, or skin infections.
Some patients experiencing severe inflammation have found an improvement by taking an 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 patients the inflammation is manageable, but in very rare cases it proves intractable, and the patient may have to switch to a different method of electrolysis.
Patients prone to skin infections after electrolysis can be given a topical antibiotic cream; Flamazine (silver sulphadiazine in a soothing cream base) has been used to good effect in many patients --- this is intended for treating burns, and electrolysis simply produces controlled, localised subcutaneous burns.
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).
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, patients are well advised to seek the advice of their chosen surgeon as to which parts must be depilated, 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 patients report using Betadine liquid to good effect, before and after genital electrolysis.
Some patients have found genital electrolysis unbearably painful even with topical anaesthetic cream and analgesics/sedatives, and for this group subcutaneous local anaesthesia may be the only solution. Good results have been obtained with use of Xylocaine 2 % with Adrenaline 1 in 200 000 . The vasoconstrictor action of the adrenaline not only extends the duration of the pain block but effects a substantial reduction in the oedema which often results from electrolysis on genital tissue. It will be necessary for the patient to have the area to be treated clearly marked, so that multiple insertions of the needle can be used to ensure that the entire area is anaesthetised --- as a guide, 5--10 ml of solution will be required for the lower scrotal flap used in peno-scrotal inversion vaginoplasty, and the pain block can be expected to remain adequate for up to three hours. In many cases this is long enough for the electrologist to clear the entire area in one session. When this technique is used on scrotal tissue, a healing period of several weeks must be allowed prior to gender reassignment surgery to allow complete healing: not only does the electrolysis itself cause localised tissue damage that may take 2--3 weeks to heal, but the subcutaneous injection may result in small haematomata which, while generally harmless, must be allowed to heal prior to surgery.
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 patients 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 patients find painful or disturbing. Some patients 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 patients with very dark hair and pale skin report good destruction of hair with no skin damage; conversely there have been problems with darker-skinned patients 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.
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 patient's money.
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.
It should be stressed once again 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.