BEYOND THE BINARY

Three experts explore the evolving role of identity-affirming care in aesthetic medicine, from patient-centred treatment to ethics and clinical best practice.

Aesthetic medicine is expanding rapidly, and emerging evidence suggests that LGBTQ+ communities engage with cosmetic and aesthetic services at disproportionately higher rates than the general population. Surveys indicate that LGBTQ+ adults are around 1.5–2 times more likely to have undergone a cosmetic procedure, with gay and bisexual men reporting some of the highest levels of engagement, particularly in facial aesthetics, body contouring and hair restoration.1

Among trans and nonbinary people, more than 60% report interest in, or previous use of, genderaffirming aesthetic treatments, including injectables, skin procedures and hairrelated interventions.2

For aesthetic clinicians this creates a dual responsibility: to deliver technically competent care and to understand the psychological, relational and identitybased contexts in which treatments are sought. This article integrates psychoaesthetic principles, clinical sexology, public policy and current evidence on LGBTQ+ health inequalities. Examining the implications of public inquiries, standards, emerging licensing regulation in England, specialist organisations, and financial safeguarding.

GAPS IN TRAINING AND STANDARDS

Despite increasing diversity among patients seeking aesthetic interventions, most training frameworks still assume a cisgender, heterosexual and binarygendered patient profile. This creates a mismatch between clinical education and realworld practice, a concern repeatedly highlighted in UK governance literature. The Joint Council for Cosmetic Practitioners (JCCP) has identified significant variation in the quality of education and training across the sector, noting that a substantial proportion of complaints relate directly to poorquality training, inadequate supervision and practitioners operating outside their scope of competence.3

The lack of cultural competency is an often overlooked example of practising out of scope. The JCCP Education and Training Standards emphasise psychologically informed practice, safeguarding literacy and the importance of understanding patient identity, vulnerability and psychosocial drivers.4 The JCCP Equality, Diversity and Inclusion (EDI) Framework further requires practitioners to deliver culturally competent care and to recognise how structural inequalities shape patient experiences.5

Similarly, the Cosmetic Practice Standards Authority (CPSA) mandates that practitioners assess psychological readiness, manage risk and ensure informed consent, particularly with patients who experience distress, dysphoria or minority stress.6

These governance frameworks align with themes emerging from public inquiries, including the Cass Review, although controversial in some of its findings, identified systemic shortcomings in psychological assessment, safeguarding and continuity of care within gender identity services.7 Although focused on youth services, its findings;fragmented pathways, inconsistent standards, insufficient training and lack of psychological oversight,mirror challenges within adult aesthetic practice. The Professional Standards Authority (PSA) and General Medical Council (GMC) have also raised concerns about variable standards, inadequate training and the need for stronger regulatory oversight in nonsurgical cosmetic practice .8-9

PATIENT PATHWAYS, ACCESS AND INEQUALITY

Access to healthcare,including aesthetic care,is not evenly distributed. Stonewall’s health report found that one in seven LGBTQ+ people avoid healthcare due to fear of discrimination, and almost one in four have witnessed or experienced homophobia or transphobia from NHS staff10 , while a 2023 study found one in eight LGBTQ+ people have experienced unequal care from healthcare staff due to their sexuality.11 These experiences shape how LGBTQ+ patients approach elective treatments. For some, private aesthetic care may feel safer or more affirming; for others, it risks becoming another site of exclusion.

Recent data from the Office for National Statistics show that lesbian, gay and bisexual individuals experience higher rates of death linked to alcohol, drug poisoning, heart disease and suicide compared with heterosexual people .12 These disparities reflect the cumulative impact of discrimination, reduced access to care and social isolation.

Clinicians must therefore consider how past discrimination affects trust, how minority stress shapes treatment motivations, and how to create psychologically safe consultation environments. This includes recognising when psychological or social factors may be influencing a patient’s expectations, readiness or decisionmaking, or when inappropriate language use, stereotyping, or exclusionary or assumptive language may undermine patient care.

To support this, clinicians should maintain uptodate knowledge of specialist psychological pathways, including services with expertise in gender, sexuality and relationship diversity (GSRD). For individuals seeking support, information and practitioner directories are available through organisations such as Pink Therapy13 ,

Multidisciplinary working may involve collaboration with sexualhealth specialists, clinical psychologists, dermatologists, endocrinologists, genderaffirming services or hairrestoration specialists. Clear referral routes help clinicians navigate complex presentations, manage risk and ensure that patients receive the right expertise.

Embedding these pathways into routine practice enhances patient safety, supports ethical decisionmaking and reinforces the profession’s commitment to inclusive, psychologically informed care.

BINARY FRAMING AND GENDER EUPHORIA

Aesthetic medicine continues to rely heavily on binary descriptors such as “feminising” and “masculinising” treatments. While clinically convenient, these categories can obscure the needs of nonbinary patients and reinforce narrow aesthetic norms. A more nuanced approach recognises that patients may seek alignment with internal identity, relational or social affirmation, relief from dysphoria or minority stress, and experiences of gender euphoria.

Gender euphoria,the positive emotional experience of one’s gender being recognised, affirmed or embodied,may “hit differently” for trans and nonbinary people because it represents not only personal authenticity but also increased social safety and relief from chronic invalidation.14

MENTAL HEALTH, IDENTITY AND TREATMENT OUTCOMES

Aesthetic outcomes cannot be separated from mental health. LGBTQ+ people experience disproportionately high rates of depression, anxiety, selfharm and suicidality.10 Gay and bisexual men show higher prevalence of body dysmorphic symptoms and appearancerelated distress compared with heterosexual men.15 The BDD Foundation emphasises the importance of early identification, psychological screening and referral pathways for patients whose motivations may be driven by distress rather than enhancement16

A psychologically informed consultation is therefore essential, particularly when working with populations already exposed to minority stress and structural inequality.

CLINICAL APPLICATIONS

Hair restoration

For many patients, hair loss is not simply an aesthetic concern but a challenge to gender expression, social identity and selfesteem. This is particularly relevant for LGBTQ+ communities: gay and bisexual men report higher levels of appearancerelated distress and hairrelated anxiety, often linked to communityspecific norms around youthfulness and masculinity.17 For transmasculine and some nonbinary patients, hair restoration or transplantation plays a role in reducing gender dysphoria and supporting gender euphoria.

In the UK, the British Association of Hair Restoration Surgery (BAHRS) provides governance on safe practice, ethical patient selection and psychological assessment, emphasising realistic expectations, long term planning and avoidance of exploitative marketing.18 The BDD Foundation notes that hairrelated concerns can be a trigger point for individuals with body dysmorphic disorder and recommends early identification and referral when patients present with disproportionate distress or compulsive checking.16

Genital aesthetics Genital aesthetic treatments require a particularly sensitive, traumainformed and relationally attuned approach. For many patients, genital appearance is closely tied to sexual identity, intimacy and relational confidence. LGBTQ+ patients may have additional layers of meaning attached to genital aesthetics, including experiences of shame or stigma, histories of medical trauma or discrimination, dysphoria related to gender identity and concerns about sexual functioning. This is especially relevant to LGBTQ+ patient experience, where the emotional and relational significance of genital or anorectal appearance is often poorly understood in clinical settings.

A related but often overlooked area is anorectal aesthetic and functional procedures, including botulinum toxin for anodyspareunia or sphincter hypertonicity’. While clinically indicated for conditions such as fissures or functional pain, some gay and bisexual men also seek this treatment to reduce discomfort during receptive anal intercourse. Many patients report that heterosexual clinicians do not understand their anxiety around anorectal appearance or function, despite this being a meaningful part of sexual identity and relational wellbeing. This mismatch can leave individuals feeling dismissed or ashamed, reinforcing barriers to care and avoidance of reengagement with healthcare services.

Research supports this disparity: recent studies show that gay, bisexual and other men who have sex with men often experience anorectal surgery differently, and that clinicians may lack awareness of the psychological, sexualidentity and relational dimensions involved.19

Within the broader context of genital aesthetics, governance bodies such as the CPSA emphasise that these procedures require enhanced consent processes, clear discussion of risks, psychological readiness assessments and robust safeguarding.6 Studies also indicate that genital dissatisfaction is significantly higher among trans and nonbinary individuals, and that genitalfocused interventions can improve quality of life when delivered within an affirming, ethical framework.20

The recent UK ban on injectable fillers in certain body areas, introduced under the Health and Care Act 2022, reflects concerns about safety, unregulated practice and rising NHS complications. Genital fillers fall within this highrisk category, reinforcing the need to work strictly within evidencebased anatomical and regulatory boundaries.21

Genderaffirming aesthetics

Genderaffirming aesthetic interventions, such as jawline contouring, lip augmentation, body shaping and skin treatments,can play a significant role in supporting psychological wellbeing, identity expression and social safety for trans and nonbinary patients. International transgender health surveys suggest that over 60% of trans and nonbinary adults have used, or are interested in using, nonsurgical aesthetic treatments as part of their journey.2

Genderaffirming aesthetics can reduce gender dysphoria, enhance gender euphoria, improve social confidence, reduce misgendering and support relational and occupational wellbeing.2 Governance frameworks, emphasise that such treatments must be delivered within a psychologically informed, identityaffirming and safeguardingoriented framework.4,6

PRP in LGBTQ+inclusive aesthetic care

Plateletrich plasma (PRP) is increasingly used in aesthetic medicine for hair restoration, skin rejuvenation and sexualwellbeing interventions. For LGBTQ+ patients, PRP may be sought for androgenrelated hair thinning, beard density or skin quality optimisation as part of genderaffirming care.

From a governance perspective, PRP is a minimally manipulated autologous blood product, and practitioners must comply with JCCP education and training standards for bloodborne procedures4 , CPSA standards for infection control and consent6 , CQC expectations where applicable, and Health and Safety Executive (HSE) requirements for sharps and waste. BAHRS guidance on PRP for hair loss emphasises realistic expectations, staged treatment planning, psychological assessment and avoidance of unproven claims.18

PRP is often marketed aggressively, and patients may be vulnerable to unrealistic promises. This underscores the need for ethical communication, evidencebased practice and financial safeguarding.

HIVinclusive aesthetic practice

Modern antiretroviral therapy means most individuals have undetectable viral loads, excellent immune function and no increased procedural risk.22 However, stigma persists, and LGBTQ+ patients living with HIV report disproportionately high rates of discrimination. Stonewall (2018) found that 13% of LGBTQ+ people living with HIV experienced unequal treatment in healthcare settings and many reported avoiding care due to fear of stigma.10 Aesthetic clinics therefore have a responsibility to ensure nondiscriminatory, evidencebased infection control. Standard precautions are sufficient for all patients; no additional measures are required for HIVpositive individuals with controlled viral loads .6 Practitioners must comply with BHIVA standards of care, the Equality Act 2010, which recognises HIV as a protected characteristic from diagnosis, and GMC guidance on nondiscrimination and consent.8,22,23 Traumainformed communication is essential, given histories of social and medical discrimination, breaches of confidentiality and stigma in sexualhealth settings.

Financial vulnerability and debt risk

A growing concern within aesthetic medicine is the financial vulnerability of patients who feel compelled to enter debt to access cosmetic treatments. LGBTQ+ individuals may face employment discrimination, family estrangement, reduced financial safety nets and pressure to conform to communityspecific appearance norms.

The Financial Conduct Authority (FCA) warns against highinterest credit arrangements in healthcare settings and highlights the need for responsible lending and transparent information.24

CONCLUSION

As the NHS prepares to publish its LGBT+ Health Inequalities Review, aesthetic medicine has an opportunity to lead by example. Pride season offers a moment for clinical reflection, a reminder that visibility, belonging and psychological safety are not seasonal themes but essential components of care.

Futureproofing the sector means embedding psychological and relational understanding into everyday practice, strengthening inclusive pathways and ensuring clinicians are equipped to support improved outcomes for LGBTQ+ patients.

This forwardlooking approach also requires readiness for the emerging nonsurgical cosmetic licensing scheme and a commitment to governance that is transparent, accountable and aligned with national standards.

Representation – across training, leadership, research and patient engagement – must be treated as a core element of clinical quality, not an optional gesture. When inclusion is structurally embedded rather than individually improvised, the sector becomes more resilient, equitable and clinically robust.

Compassion, respect, connection and joy should guide this evolution, shaping a future in which aesthetic practice is genuinely inclusive, identityaffirming and grounded in the principles of equity and patient safety— ultimately contributing to better experiences and better outcomes for all.

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