Abstract
Purpose: Subcutaneous injections, or “fillers,” are used illicitly and in large quantities by trans women for feminization. They are associated with severe complications, but data on their use are limited, especially in places with widespread access to safe gender-affirming care. Our analysis seeks to assess the prevalence, correlates, and complications of filler use to inform prevention and treatment.
Methods: A secondary analysis of cross-sectional survey data from the Trans* National Study conducted from May 2016 to December 2017 of 631 adult trans women in the San Francisco Bay Area, California, recruited using respondent-driven sampling.
Results: Around 65/631 participants (10.3%) reported filler use. Filler use was highest among Latinas (21.3% vs. 3.8% among whites, p<0.001), high school graduates (22.6% vs. 1.7% among college graduates, p<0.001), and those with a history of being undocumented (31.7% vs. 16.3% among documented immigrants and 6.4% among U.S. natives, p<0.001). Filler users had higher odds of engaging in sex work ever (odds ratio [OR] 3.3, p<0.001) and in the last 6 months (OR 2.00, p=0.049). The majority of filler users (78.5%) reported a physical complication, including infectious and inflammatory responses, coagulopathies, and neuropathies.
Conclusion: Filler use was high among participants, despite availability of gender-affirming care and prevalence of complications. Filler use was highest among those with social, economic, and political vulnerabilities. Thus, filler use might be associated with structural factors that reduce access to safer methods of feminization. Addressing these factors, increasing access to safe gender-affirming care, and developing protocols for filler-related complications are needed.
Keywords: dermal fillers, emigration and immigration, feminization, Hispanic Americans, subcutaneous injection, transgender persons
Introduction
“Fillers” are subcutaneous injections used by trans women to feminize their appearance.1 While fillers are often referred to as “silicone” in the community, these injections can be any substance, including silicone, collagen, saline water, and other substances like mineral oil or cooking oil.2–5 Trans women find fillers on the streets or at “pumping parties” where “pumpers” inject materials purported to be medical-grade silicone.6 Fillers can be injected illicitly in any quantity into almost any part of the body, including the breast, buttocks, hips, and calves.2,3,7 However, the U.S. FDA has not approved injectable silicone for large-scale soft tissue enhancement, and use is not approved for the breast, the buttocks, or muscle tissue (e.g., calves).8
Trans women use fillers to fulfill unmet gender affirmation needs.6,9 Access to gender-affirming care for trans women is limited by availability, insurance policies, cost, and experiences of discrimination in the medical system.10 These structural limitations result in unmet need for gender-affirming care like hormones, surgeries, and other procedures.11 As a result, many trans women use other resources outside the medical system for gender-affirming care, including fillers. Studies have found that trans women use fillers to appear more feminine, to improve their safety so they are not recognized as transgender, and to improve their quality of life.5,6,12 Ethnographic research from Puerto Rico found that many trans women who used fillers also engaged in sex work.13
Fillers used in large quantities and in anatomic locations other than the face or hands can have serious health complications.14,15 Case reports have documented severe complications, including multisystem organ failure, pulmonary emboli, respiratory distress, cellulitis, acute granulomatous pneumonitis, and death.3,7,12,14–18 Filler use among trans women contributes to health disparities because treatment is often limited, and education dedicated to treating complications is poor in medical education.5,19 Even more, little population-based data exist on filler use, complications, and associated behaviors and social outcomes among trans women, especially in the continental United States. Population-based prevalence data on filler use among trans women are needed to investigate correlates and health consequences to inform prevention and treatment within this underserved community.
We conducted a secondary analysis of data from a large study of trans women in the San Francisco Bay Area to characterize and describe filler use and related complications. We also assessed factors associated with filler use to better understand what groups within the population are most at risk for use and filler-related complications to most effectively target prevention and treatment interventions.
Methods
This is a secondary analysis using cross-sectional survey data from the Trans* National Study conducted from May 2016 to December 2017 in the San Francisco Bay Area, California. The Trans* National Study used respondent-driven sampling to recruit a population-based sample of trans women 18 years of age or older. The sample was recruited to reflect the diverse demographic characteristics of trans women in the San Francisco Bay Area. Human subjects' approvals for the study were obtained by the University of California, San Francisco Committee on Human Subjects Research.
Correlates of filler use examined were chosen a priori based on findings from the extant literature. Demographic factors in this analysis were race/ethnicity, age, gender identity, educational level, nativity, a history of ever being undocumented, housing status, and average monthly income. Participants self-reported their race/ethnicity, and were characterized as Latina, white, black/African American, Asian, Native American, Pacific Islander/Native Hawaiian, mixed, or “other” race/ethnicity. Participants reported their gender by selecting a pre-assigned category (i.e., male, female, transgender female/trans woman, androgynous/ambigender, genderqueer/genderfluid, and questioning) or self-reporting a distinct gender. Participants were defined as having less than a high school education if they never attended school or had completed grades 1–11. Participants were defined as having some college or technical degree if they completed an AA degree, a technical degree, or some college. Participants were defined as having some college degree or beyond if they completed a Bachelor's degree or post-graduate studies. Participants who owned their own house, rented a house or an apartment, or lived with partners, friends, family, or guardians were considered to have stable housing, whereas those in transitional housing, couch surfing, or homeless were defined as having unstable housing.
Participants were defined as having used fillers if they had received one ever, regardless if they still had it. Participants were asked to self-report filler-associated complications from a pre-determined list based on the extant literature. Participants could select multiple options for substance injected and physical complications, as many participants reported multiple fillers. Participants who had received a filler were asked only about whether their most recent provider was a medical professional.
Participants were asked about a variety of behaviors and social outcomes. Participants were defined as not using alcohol or club drugs before sex if they declined alcohol, ketamine, gamma-hydroxybutyrate, or Rohypnol use before sex in the last 12 months. Participants who answered “not at all” or “a little bit” for importance of passing for safety or self-esteem were combined during secondary analysis. For reported quality of life, participants who answered “very poor” or “poor” were combined and participants who answered “good” and “very good” were combined during secondary analysis. Participants were defined as having a past diagnosis of depression, PTSD, or anxiety if a health care professional had made a diagnosis ever. Participants were defined as having engaged in sex work if they reported exchanging sex for money, goods, or housing.
Venngage was used to visually represent the percent of trans women who received fillers in each anatomical site (Fig. 1) and the geographic city, state, or country where trans women reported receiving a filler (Fig. 2). Participants could report more than one anatomical site and more than locale. Descriptive statistics were used to calculate demographics and to determine the prevalence of filler use, associated physical complications, and anatomic locations of filler use. A two-sided Fisher's exact test was used to compare filler use by demographic factors, and significant differences between groups were those with a p-value of <0.05 (Table 2). The two-sided Fisher's exact test was also used to compare filler use by behavior and social outcome, and significant associations were defined as those with a p-value <0.05 (Table 3). The odds ratios (ORs) were calculated, excluding individuals who declined to respond to the social or behavioral outcomes (17 participants). Adjusted odds ratios and a logistic regression were not used in the analysis because of the lack of research on filler use among trans women to guide adjusted and multivariate analyses.
FIG. 1.
Number of filler users by anatomic site with rank order of prevalence. Number (%) of filler users who reported a filler at the indicated anatomic site.
FIG. 2.
Number of filler users by geographic location. Number of filler users who reported receiving a filler at the indicated geographic site.
Table 2.
Demographics of Filler Users Compared to Participants Who Never Used Fillers (n=631)
| Demographic | Filler users (n=65) | No filler use (n=566) | p |
|---|---|---|---|
| Race | |||
| White | 7 (3.8%) | 176 (96.2%) | 0.000** |
| Latina | 39 (21.3%) | 144 (78.7%) | |
| Black/African American | 9 (8.2%) | 101 (91.8%) | |
| Asian | 1 (4.4%) | 22 (95.6%) | |
| Native Hawaiian or Pacific Islander | 1 (12.5%) | 7 (87.5%) | |
| Native American | 0 (0.0%) | 5 (100.0%) | |
| Other/multirace | 8 (6.7%) | 111 (93.3%) | |
| Age (years) | |||
| 18–24 | 1 (1.4%) | 69 (98.6%) | 0.012** |
| 25–34 | 14 (8.3%) | 155 (91.7%) | |
| 35–44 | 22 (15.3%) | 122 (84.7%) | |
| 45–59 | 22 (10.8%) | 181 (89.2%) | |
| ≥60 | 6 (13.3%) | 39 (86.7%) | |
| Mean (SD) | 43.5 (10.8) | 40.2 (13.2) | |
| Gender identity | |||
| Female | 28 (9.9%) | 256 (90.1%) | 0.345 |
| Transgender female or trans women | 35 (12.1%) | 255 (87.9%) | |
| Genderqueer/genderfluid | 1 (4.4%) | 22 (95.6%) | |
| Other (androgynous/ambigender/questioning/additional sex or gender) | 1 (2.9%) | 33 (97.1%) | |
| Sex assigned at birth | |||
| Male | 65 (10.4%) | 563 (89.6%) | 1.000 |
| Was not assigned a sex | 0 (0.0%) | 3 (100.0%) | |
| Highest level of education | |||
| Less than high school | 28 (22.6%) | 96 (77.4%) | 0.000** |
| High school diploma/GED | 14 (7.8%) | 166 (92.2%) | |
| Some college/technical degree | 21 (10.1%) | 188 (89.9%) | |
| College degree and beyond | 2 (1.7%) | 116 (98.3%) | |
| Nativity | |||
| Born in United States | 32 (6.4%) | 470 (93.6%) | 0.000** |
| Born outside the United States | 33 (25.6%) | 96 (74.4%) | |
| Ever been undocumented | |||
| Yes | 25 (31.7%) | 54 (68.3%) | 0.000** |
| No | 8 (16.3%) | 41 (83.7%) | |
| Don't know | 0 (0.0%) | 1 (100.0%) | |
| Born in the United States | 32 (6.4%) | 470 (93.6%) | |
| Housing situation | |||
| Unstable housing | 32 (10.1%) | 284 (89.9%) | 0.897 |
| Stable housing | 33 (10.5%) | 282 (89.5%) | |
| Residency status | |||
| San Francisco County resident | 59 (90.8%) | 407 (71.9%) | 0.43 |
| Non-San Francisco County resident | 6 (9.2%) | 159 (28.1%) | |
| Average monthly income before taxes | |||
| Less than $701 | 23 (14.3%) | 138 (85.7%) | 0.217 |
| $701–$954 | 12 (8.0%) | 137 (92.0%) | |
| $955–$1599 | 12 (7.8%) | 142 (92.2%) | |
| More than $1600 | 17 (10.6%) | 143 (89.4%) | |
| Declined | 1 (14.3%) | 6 (85.7%) | |
p<0.05.
Table 3.
Characteristics of Filler Use (n=65)
| N (%) | |
|---|---|
| Injection frequency | |
| 1 | 19 (29.2) |
| 2–4 | 23 (35.4) |
| 5–9 | 17 (26.2) |
| More than 10 | 6 (9.2) |
| Substance injected | |
| Silicone | 55 (84.6) |
| Mineral oil | 5 (7.7) |
| Biopolymer | 2 (3.1) |
| Collagen | 1 (1.5) |
| Other | 5 (7.7) |
| Most recent provider viewed as medical professional | |
| Yes | 28 (43.1) |
| No | 36 (55.4) |
| Don't know | 1 (1.5) |
| Any physical complication | |
| Yes | 51 (78.5) |
| No | 14 (21.5) |
| No. of complications | |
| 0 | 14 (22.7) |
| 1–2 | 17 (25.8) |
| 3–5 | 17 (25.8) |
| 6–9 | 9 (13.6) |
| 10+ | 8 (12.1) |
| Physical complication | |
| Pain at the injection site | 28 (43.1) |
| Swelling | 28 (43.1) |
| Hematoma | 26 (40.0) |
| Erythema/redness | 24 (36.9) |
| Migration/change in shape | 24 (36.9) |
| Hypersensitivity reactions | 18 (27.7) |
| Hardened skin (induration) | 14 (21.5) |
| Itchy skin | 14 (21.5) |
| Numbness/loss of feeling | 13 (20.0) |
| Fever | 10 (15.4) |
| Cellulitis | 10 (15.4) |
| Granuloma formation | 9 (13.8) |
| Rejection of foreign body | 8 (12.3) |
| Bleeding | 8 (12.3) |
| Nausea or vomiting | 7 (10.8) |
| Rash | 6 (9.2) |
| Weight loss | 2 (3.1) |
| Pulmonary embolism | 2 (3.1) |
| Ulceration | 1 (1.5) |
| Other | 4 (6.2) |
Results
The sample consisted of 631 trans women. The age of participants ranged from 18 to 75 years with a mean age of 40 years. The most common racial identities reported were Latina (29%) and white (29%), followed by black/African American (17.4%) and other/multiracial (18.9%). Most participants were assigned male sex at birth, and 91% identified as a woman or as a trans woman. Educational attainment varied significantly, with most participants (80.3%) having received at least a high school diploma or GED, while only 18.7% received a college degree or more. Most participants were born in the United States, and 20.4% were born elsewhere. Of those born outside of the United States, 61.2% reported a history of being undocumented. Of the 79 participants with a history of being undocumented, 77 (97.5%) identified as Latina and 2 (2.5%) identified as Asian. Half (50%) of the sample was unstably housed (couch surfing, homeless, or in transitional housing). More than half of all participants had incomes below the federal poverty line, and only 25.4% of participants had a monthly salary above $1600. Of 631 participants, 466 (73.9%) lived in San Francisco County and based on income, qualified for public insurance and local gender-affirming access programs (Table 1).
Table 1.
Demographics of Trans* National Study (n=631)
| Demographic | N (%) |
|---|---|
| Race | |
| White | 183 (29.0) |
| Latina | 183 (29.0) |
| Black/African American | 110 (17.4) |
| Asian | 23 (3.6) |
| Native Hawaiian or Pacific Islander | 8 (1.3) |
| Native American | 5 (0.8) |
| Other/multirace | 119 (18.9) |
| Age (years) | |
| 18–24 | 70 (11.1) |
| 25–34 | 169 (26.8) |
| 35–44 | 144 (22.8) |
| 45–59 | 203 (32.2) |
| ≥60 | 45 (7.1) |
| Mean (SD) | 40.5 (13.0) |
| Gender identity | |
| Female | 284 (45.0) |
| Transgender female or trans women | 290 (46.0) |
| Genderqueer/genderfluid | 23 (3.6) |
| Other (androgynous/ambigender/questioning/additional sex or gender) | 34 (5.4) |
| Sex assigned at birth | |
| Male | 628 (99.5) |
| Was not assigned a sex | 3 (0.5) |
| Highest level of education | |
| Less than high school | 124 (19.7) |
| High school diploma/GED | 180 (28.5) |
| Some college/technical degree | 209 (33.1) |
| College degree and beyond | 118 (18.7) |
| Nativity | |
| Born in United States | 502 (79.6) |
| Born outside the United States | 129 (20.4) |
| Ever been undocumented | |
| Yes | 79 (12.5) |
| No | 49 (7.8) |
| Don't know | 1 (0.1) |
| Born in the United States | 502 (79.6) |
| Housing situation | |
| Unstable housing | 316 (50.1) |
| Stable housing | 315 (49.9) |
| Residency status | |
| San Francisco County resident | 466 (73.9) |
| Non-San Francisco County resident | 165 (26.1) |
| Average monthly income before taxes | |
| Less than $701 | 161 (25.5) |
| $701–$954 | 149 (23.6) |
| $955–$1599 | 154 (24.4) |
| More than $1600 | 160 (25.4) |
| Declined | 7 (1.1) |
| Ever used fillers | |
| Yes | 65 (10.3) |
| No | 566 (89.7) |
Of 631 participants, 65 (10.3%) reported having ever used fillers. Significantly more Latinas used fillers compared to white participants (21.3% vs. 3.8%, p<0.001). More than half (60%) of filler users identified as Latina. Trans women between the ages of 35 and 44 had significantly higher filler use compared to other age categories (15.3% vs. 10.8% among 45–59 year-old participants and 1.4% among 18–24 year-old participants, p=0.012). Trans women without a high school degree were more likely to have used fillers compared to those who had completed college (22.6% vs. 1.7%, p<0.001). More trans women born outside the United States had used fillers than those born in the United States (25.6% vs. 6.5%, p<0.001). Trans women with a history of being undocumented used fillers more than documented immigrants (31.7% vs. 16.3% among documented immigrants and 6.4% among U.S. natives, p<0.001). All trans women who reported using fillers with a history of being undocumented identified as Latina (Table 2).
Among the 65 participants who had ever received a filler, 46 participants (70.8%) had received more than one filler in their lifetime and 23 participants (35.4%) reported having received five or more fillers in their lifetime. Of those with fillers, most reported using silicone (84.6%), while others reported having fillers made of mineral oil (7.7%), biopolymers (3.1%), collagen (1.5%), and other substances (7.7%). Of the 45 trans women who remembered the date of their latest filler placement, 11 participants (24.4%) received their most recent filler in or after 2013, after Gender Health SF, a publicly funded surgery access program, began offering gender-affirming surgeries for eligible uninsured San Francisco residents. Of these 11 participants, 9 (81.8%) resided in San Francisco County and likely would have been eligible for gender-affirming surgery services at the time.
More than half (55.4%) of participants who used fillers reported that they received a filler from someone who was not a medical professional, and the majority (78.5%) reported a filler-related complication. Over half (51.5%) of participants who had received a filler had more than three associated physical complications, and 25.7% reported more than five physical complications after receiving a filler. The most common complications reported included pain at the injection site (43.1%), swelling (43.1%), hematoma (40.0%), erythema (36.9%), and migration of the filler (36.9%). Other complications included hypersensitivity reactions (27.7%), hardened skin (21.5%), itchy skin (21.5%), numbness (20.0%), fever (15.4%), cellulitis (15.4%), granuloma formation (13.8%), rejection of the foreign body (12.3%), and bleeding (12.3%). Less common complications included nausea or vomiting, rash, weight loss, and pulmonary embolism (Table 3).
Over half (58.5%) had a filler in their buttocks, and many had injections in their hips (44.6%), face (35.4%), breast (16.9%), and thighs (16.9%) (Fig. 1). The most commonly reported metropolitan area was San Francisco, where 28 participants (43.1%) had received a filler. Other U.S. cities included the Los Angeles metropolitan area, Miami, New York City, Philadelphia, Chicago, Honolulu, Dallas, El Paso, Houston, San Antonio, Durant, and Winston-Salem. Among participants who had received fillers, 21 (32.3%) individuals reported receiving fillers outside of the United States, including Mexico and Honduras. One fifth of participants (20%) received fillers in Tijuana, the second most reported city (Fig. 2).
Participants who used fillers had significantly greater odds of having engaged in sex work ever (OR 3.3, p<0.001) and in the last 6 months (OR 2.00, p=0.049) than those who had not used fillers. We did not find any significant association between filler use and substance use (drugs or alcohol) before sex, importance of passing for safety or self-esteem, the ability to live full time as their gender, quality of life, or rates of depression, PTSD, or anxiety (Table 4).
Table 4.
Social, Behavioral, and Psychological Outcomes and Their Association to Filler Use (n=614)
| Filler users |
No filler use |
Odds ratio | p | |||
|---|---|---|---|---|---|---|
| N | % | N | % | |||
| Sex work ever | ||||||
| Yes | 55 | 84.6 | 342 | 62.3 | 3.3 | 0.000** |
| Sex work in last 6 months | ||||||
| Yes | 14 | 21.5 | 66 | 12.0 | 2.00 | 0.049** |
| Club drug use before sex | ||||||
| Yes | 3 | 4.6 | 20 | 3.6 | 0.726 | |
| Alcohol use before sex | ||||||
| Yes | 20 | 30.8 | 217 | 39.5 | 0.180 | |
| Importance of passing for safety | ||||||
| Not at all/A little bit | 11 | 16.9 | 85 | 15.5 | 0.836 | |
| Some what | 10 | 15.4 | 101 | 18.4 | ||
| A lot | 44 | 67.7 | 363 | 66.1 | ||
| Importance of passing for self esteem | ||||||
| Not at all/a little bit | 17 | 26.1 | 125 | 22.8 | 0.696 | |
| Some what | 13 | 20.0 | 100 | 18.2 | ||
| A lot | 35 | 53.9 | 324 | 59.0 | ||
| Living full time as their gender | ||||||
| Yes | 63 | 96.9 | 526 | 95.8 | 1.000 | |
| Reported quality of life | ||||||
| Very poor/poor | 6 | 9.2 | 73 | 13.3 | 0.243 | |
| Neither poor nor good | 21 | 32.3 | 126 | 23.0 | ||
| Good/very good | 38 | 58.5 | 350 | 63.2 | ||
| Past diagnosis of depression | ||||||
| Yes | 31 | 47.7 | 332 | 60.5 | 0.061 | |
| Past diagnosis of PTSD | ||||||
| Yes | 21 | 32.3 | 188 | 34.2 | 0.784 | |
| Past diagnosis of anxiety | ||||||
| Yes | 30 | 46.1 | 301 | 54.8 | 0.191 | |
p<0.05.
PTSD, post-traumatic stress disorder.
Discussion
The prevalence of filler use in the San Francisco Bay Area was striking, given the availability of gender-affirming surgery access and improving public and private coverage of this care, although wide variability exists in private insurance coverage.20–23 A number of clinics, including Trans Tuesdays and TransVision, have increased access to gender-affirming primary medical care in the San Francisco Bay Area.24 In San Francisco, the Gender Health program was started in 2012 to offer gender-affirming surgery and support services for trans and nonbinary residents of the city and county of San Francisco. To meet the ongoing need for surgical procedures, the Gender Health program also began offering gender-affirming surgeries with public coverage for San Francisco residents.25 Although most participants received their fillers before Gender Health was founded, nine San Francisco residents received a filler after the program began, despite eligibility for surgery services. A San Francisco study showed that not being able to see a provider because of scheduling issues and wanting a quicker gender transition were reasons that trans women sought hormones from illicit sources.26 Similarly, trans women may desire the immediate effects of fillers rather than wait for surgery. More research is needed to understand prevalence of filler use in areas with improving surgery access and why fillers continue to be used over medically supervised surgeries.
Significantly, our study also found that trans women from vulnerable backgrounds, including Latinas, immigrants with a history of being undocumented, those with low educational attainment, and those who engaged in sex work, were more likely to use fillers than their counterparts. Almost all of the immigrants who reported a history of being undocumented were Latina, so the association seen between immigration status and Latina identity with filler use is likely overlapping and multifactorial. We hypothesize that immigrants with a history of being undocumented may be those at most risk of using fillers for feminization because of concerns for their legal status in the United States. Other studies have also found that Latina trans women often obtain body modification procedures because of intracultural ideals surrounding curvaceous femininity.27,28 The overlapping nature of these findings suggest that participants with a history of being undocumented, all of whom were Latinas in our study, may have a desire to appear more feminine, but fear accessing gender-affirming services because of immigration policies and the threat of deportation for people who engage in federally funded health care.29
We also found that individuals with lower educational attainment were more likely to pursue fillers. Education may be a marker of low socioeconomic status. Trans women, especially those from ethnic minority groups, often contend with substantial discrimination in education, which is known to affect their access to educational degrees that impacts employment prospects and upward mobility.10 The correlation between education and filler use may reflect a lack of income to afford gender-affirming surgeries as a result of lower educational and employment opportunities.
Finally, we found that filler use was significantly associated with sex work. In the face of pervasive societal discrimination, some trans women do sex work for income.30 Additional ties between sex work and fillers have been found in ethnographic research from Puerto Rico. Researchers there found that some trans women pursue sex work as a means to acquire fillers, and trans women often learn about fillers through networks of sex workers; some trans women also use fillers to meet aesthetic desires expressed by their clients, which then impacts their income.13 An urgent need for income may make the lengthy recovery process after surgery impossible for trans women who engage in sex work.
Interestingly, filler use was highest among participants between the ages of 35 and 44, and was not as prevalent among youth. This finding is consistent with other research, which has found that younger trans women may focus on hormones earlier in their transition, and more permanent changes to their physical appearance in their middle age years. This may be the result of improved capacity to manage the side effects of fillers as well as the ability to acquire the capital to purchase them.6 An alternative explanation is that younger trans women may be more likely to use hormones and surgery to affirm their gender, or they may choose to not use gender-affirming services at all.
Despite the disparities we saw in filler use, perhaps the most immediate public health issue in need of attention is filler complications. Over half of the participants had three or more physical complications. These complications varied widely, including infectious and inflammatory responses, coagulopathies, and neuropathies. Participants reported serious complications like cellulitis, ulceration, hypersensitivity reactions, foreign body rejection, pulmonary embolus, and granuloma formation. Some of these complications can cause serious disease and can be life-threatening. The high prevalence of complications brings into question the safety of these injections, especially in context of the ways in which they were administered by nonmedical professionals. Medical education is scant on how to treat filler complications among trans women in hospital and primary care settings. There is an immediate need for medical protocols and education to address filler-associated complications. In the future, increasing access to safer methods of gender affirmation, like medically supervised hormones and surgery, may also help provide safer alternatives for feminization and reduce the prevalence of complications.
Despite the high prevalence of associated physical complications, fillers were highly desired, as most participants who had received fillers chose to have more than one. Therefore, understanding why trans women pursue fillers in important to meeting their health care needs. With this understanding, health education and harm reduction methods can be developed to counsel trans women who may be considering fillers. Discussing the benefits and risks of fillers with trans women is important to ensuring they have the information needed when making a decision on whether or not to use fillers.
Our study is not without limitations. The cross-sectional nature of the data collected limited our ability to interpret temporality among some of the observed factors, as only the date of the most recent filler was collected. Our study also utilized self-reporting of filler-associated complications rather than electronic health record data, which may result in underreporting or overreporting of medical complications (importantly, death could not be reported). Despite these challenges, to our knowledge, this article is the first to describe filler use in an area with access to public coverage for gender-affirming surgeries. We have shown that the some of the most vulnerable members of the trans population are using fillers to feminize their appearance. Therefore, addressing their use will not only be addressing the health needs of trans women, but also the most vulnerable people among them.
IRB Approval
Human subjects' approvals for the study were obtained by the University of California, San Francisco Committee on Human Subjects Research.
Acknowledgments
We would like to acknowledge the Trans* National research team and the trans women participants who shared their lives with us to improve public health outcomes for all trans women.
Abbreviation Used
- PTSD
post-traumatic stress disorder
Author Disclosure Statement
No competing financial interests exist.
Funding Information
This study was supported by the National Institute on Minority Health and Health Disparities (R01MD010678).
Cite this article as: Sergi FD, Wilson EC (2021) Filler use among trans women: correlates of feminizing subcutaneous injections and their health consequences, Transgender Health 6:2, 82–90, DOI: 10.1089/trgh.2020.0035.
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