Surrounded by decadent designs of contemporary art, blended nicely with the elegance of crystal chandeliers which illuminate the majestic foyer, I sit in the hotel business center of the Crowne Plaza in Festival City, Dubai, overlooking the Canal of Dubai Creek. I have just completed the three-day conference of The Fourth Annual Middle East International Dermatology and Aesthetic Medicine Conference and Exhibition and have been greatly enlightened into some of the culture in the Middle East that is unfamiliar to us professionals in America.

The days were completely packed with topics such as treatments, chemical peels, skin conditions, body contouring, injectables, radiofrequency, aesthetic gynecology, hair treatments for hair loss, anatomy of face and vagina, how to manage scarring, treating hypo and hyperpigmentation, and many more laser machines to help treat all types of aesthetic needs. With 183 classes and workshops provided during the conference, I chose to narrow the attention on learning about the topics that cater to the Middle Eastern regions.

PSORIASIS

The first class I attended was “Stigmatization Among Arabic Psoriatic Patients in the United Arab Emirates.” The speaker was Dr. Dimitre Dimitrov, a dermatologist at Royal Medical Wing Al Mafraq Hospital SKMC in Abu Dhabi. He spoke of the importance of working with the psychological and psycho-social of patients. Many people in the Middle East diagnosed with psoriasis suffer from depression and anxiety, which leads to a high rate of suicides. They believe that they have a mark on their skin which makes them unacceptable in their society. They are alienated, denied affection by others, and are perceived negatively not only amongst their peers but all ages. He emphasized the importance of not only treating the patient’s skin condition but also of being an active listener and hearing the concerns of the patient’s mental health to help prevent suicides by being proactive in treating the depression, as well.

VITILIGO

Dr. Saad Al Talhab, SAUDIDERM dean of college of medicine, medical director of Derma Clinics, consultant, and dermatologist at Al-Imam Mohammad Ibn Saud Islamic University Riyadh, spoke on the topic of “Medical and Physical Depigmentation Therapies in Vitiligo.” He began his topic by showing a side-by-side, before and after picture of Michael Jackson in the 1980s and Michael Jackson in the 2000s. He started with, “I believe everyone in the room knows this man? We all know that he did not have vitiligo.” The attendees in the room laughed. “It was proven that he had been applying a bleaching cream to his skin. The toxicology report after his death showed a high volume of Cream Ben.”

As I sat through this class and many more classes, the doctors kept repeating the words “dark skin” when speaking of people with darker pigmented skin. They did not refer to African, brown, or black to describe people of varying colors. Only a couple of doctors referred to the Fitzpatrick scale. When they spoke of lighter pigmented skin tones, they would use the words Caucasian or European. I never once heard throughout the duration of the conference by any speaker or attendee the word white to refer to a lighter skin tone. They would, however, say Middle Eastern skin in reference to people of the Middle East.

I did not know when I first sat to attend the discussion of depigmenting vitiligo, the importance of this topic here in the Middle East. Any classes of depigmenting the skin were highly attended and the attendees seemed to have more of an emotional interaction during the discussions than any other topics discussed. I was able to speak to Dr. Husain Juma of Bahrain with Global Dermatology. He spoke on the topic of vitiligo and social media. I needed to know why vitiligo brought out some anger during the discussions and he was very helpful in explaining the reaction to me. He told me that vitiligo has a long-standing history in the Middle East. In not only the Arabic literature (the Abras) that dates back thousands of years, but also the Islamic religion, vitiligo is considered to be related to leprosy and albinism. These three skin conditions are considered to be an infection that is contagious and can be spread to others. Those with vitiligo are outcast – people will not eat with them, they will not shake their hands, no one will marry them. And this applies not only to the person that has vitiligo, but anybody in the whole family. Dr. Juma spoke of his aunt who is 40 years of age and has vitilgo. She has never married, never carried a job, and stays confined to her home. She does not want to show her vitiligo out of respect to her family in fear that they could be rejected. A lot of vitiligo patients suffer from emotional stress, psychological well-being, social isolation, and lifestyle changes. Parents that have a child with vitiligo wish that they would have been diagnosed with cancer instead of vitiligo because with cancer they would be accepted in society. Parents with daughters that have vitiligo know that their daughter will not be able to get married. Vitiligo affects more than just the patient, as the family suffers, as well, in the Middle East.

Women and men in the Middle East go to great lengths to depigment their skin if they have vitiligo. They spend a lot of money seeking a solution to their problem because they do not want to be stigmatized against for having this “contagious infection,” according to their beliefs. Creams and laser treatments have been successful in treating vitiligo but there are areas on the skin that are 100%t untreatable, which are periangual and other hairless areas. The successful use of creams and lasers that have been able to treat vitiligo and bring uniformity to the skin bring marriages and happiness to these individuals and families.

The question does arise, however – once the patient is 100% depigmented and they marry –whether they are obliged to tell their groom-to-be or bride-to-be that they had vitiligo. Some people believe that a person who had vitiligo needs to share that information prior to getting married. There was a case where a husband found out his wife had been depigmented and divorced her after two months of marriage. Many cases like that are common in the Middle East and vitiligo gives grounds for a divorce.

There have also been cases of the transference of bleaching cream being used by the wife, depigmenting the husband’s hands and abdominal area from her applying the cream on her body. Women who depigment their body can also transfer the cream to their children during breast feeding and holding them where the cream is on their skin. These bleaching creams work the best to depigment skin and help treat vitiligo but are also strong enough to bleach other people’s skin that come into contact with it.

Some people who are told that they are unable to be treated for their vitiligo will seek out their own way to treat it. There was a case where a woman used a bleaching cream around her eye, which is highly inadvisable by doctors, and it worked. The darker pigment around her eye was completely gone. She then decided to get eyelash extensions and the pigmentation around her eye came back and, when it came back, it was even darker than before. That is the side effect of some bleaching creams, as there are environmental factors that can cause pigmentation reoccurrence.

Sometimes, the bleaching cream mixed with uncontrollable variables causes a lighter pigment within the skin. When people seek their own treatments, it leaves room for a higher chance of psychological problems if they are unsuccessful or make the vitiligo worse. Dr. Luma spoke on vitiligo and social media and the awareness vitiligo has received because of social platforms such as Instagram and Facebook. Many people are able to connect through cyberspace to others that have vitiligo and it is making people in the Middle East psychologically healthier. They are able to see others living normal lives with vitiligo and it gives them hope. Although the social networks are great for those with vitiligo to see they are not alone, there was an instance of a doctor recommending, with error, patients to “come out” as having vitiligo. He told one of his highly respected Middle Eastern celebrity patients to come out and tell people that he has vitiligo. For many years, this male celebrity had kept hidden his vitiligo from the public, in fear of rejection. He finally announced having vitiligo. The doctor saw him a few months later and asked him if he had any regrets. The male celebrity said he did. He told the doctor that his sister now has been outcasted and it has been hard for her to get married. He cautioned doctors to not push patients to “come out” and to take it as a case-by-case basis because there is still the stigma that vitiligo is a contagious infection. Multiple doctors at the conference kept reiterating the importance of excellent patient counseling from day one to help patients achieve positive mental health as they treat their vitiligo.

AESTHETIC GYNECOLOGY

“Stigma” was a word that was used numerous times in various topics throughout the conference. In the Middle East, there is history of certain beliefs and standards that stigmatize an individual or family. Aesthetics is very important in the culture and marriage is of utmost importance. Every family wants their daughter to get married. It brings shame to the family and can even outcast the family if the daughter cannot get married due to aesthetic appearances. Once the daughter is married there are other stigmatizations that exist and that is in regards to sex. A woman’s sexual health is just as important as her aesthetic appearance.

I was fascinated by the topic of aesthetic gynecology. I had my own reservations believing that women in the Middle East, are concerned with their vaginal area being aesthetically pleasing. I quickly learned that not only American women want to feel beautiful from head-to-toe, so do women in the Middle East. I had the great honor to interview Dr. Sherif El Wakil, founder and medical director at DrSW Clinics and Royale Skin Clinics-London, United Kingdom, president of the International Association of Aesthetic Gynecology and Sexual Wellbeing (IAAGSW-UK), and founder of the “O Concept” non-surgical, tailor-made, sexual aesthetic treatment for both him and her in Marylebone, United Kingdom and London, United Kingdom. He said female sexual dysfunction is at 50% from a study that had been performed. 40% of female sexual dysfunction leads to psychological distress, 20% have never experienced orgasms, and only 14% of women speak to their partner about their sexual desires. He said in the Middle East there exists a big stigmatization on the topic of sex and hopes that there may be more dialogue in the future before marriage to prepare couples of good sexual health because many women in the Middle East’s first sexual experience is when they get married to their husband. It is still very taboo to discuss sex in the Middle East and raising awareness will help women to search for treatment. I asked him about the women wearing black covering their entire body from their head to their feet and exposing only their eyes. He referred to them as “veiled women.” I asked him if the veiled women seek aesthetic gynecology. He said absolutely. He treats many veiled women. He said even though they are veiled, they have Instagram, are connected to social networks, and follow celebrities and latest trends and want to feel beautiful aesthetically just like other women.

What is aesthetic gynecology? It helps to transform female gynecology. Why are women seeking aesthetic gynecology in the Middle East and around the world? A collection of doctors from France, Italy,  the United Kingdom, and Saudi Arabia repeated the same reasons: they are wanting to treat their vaginal atrophy; some women say that sex doesn’t feel the same anymore, so they want to tighten their vaginal wall; women want to treat vaginal laxity syndrome, which usually causes urinary incontinence; they are wanting to treat the sensation during sex and to heighten the orgasm; women want to treat pain or discomfort during sex – two-thirds of women report episodes of pain during sex, according to the latest study; and lastly, women are embarrassed by the appearance of their vagina and want to make it more aesthetically appealing.

What treatments can be performed during aesthetic gynecology? Vaginal rejuvenation can be performed to help tighten the vaginal wall, leading to more pleasurable sex for the woman and man. Dr. Rashad Haddad, senior consultant of the French Board and member of the French College of Obstetrics & Gynecology, stressed the benefits of using a laser because the longer the wavelength, the deeper the penetration into the tissue, and the repetitive pulse helps to create the rejuvenation effect. He spoke of the functional mental disorder women have because of their vaginal laxity. Women suffer from low self-esteem and depression and have a low sexual desire. When they receive a vaginal rejuvenation to treat their vaginal laxity it helps to treat this functional mental disorder.

Vaginal augmentation is a way to treat the vagina aesthetically but it also can help treat sensation. Dr. Matt Stefanelli, MD, MBA, French and European Board of Plastic Surgeon iClass Anatomy and ISAAMS director, ISGAPS director Worldplast Charity Foundation, director Paris, France, received a patient who had emigrated from South Africa. She had been a victim of vaginal mutilation where her labial folds had been removed, as well as her clitoris, so she would not experience any pleasure nor sensation during sex. He was able to perform a surgery where he took the remainder of her clitoris and brought it back into her original anatomical structure, allowing her to experience sexual pleasure.

Fillers of all kinds can be injected into the labia majora to create a fuller appearance into the labia. The fillers can consist of a microfat transfer or nanofat transfer, which last longer than the alternative fillers of various kinds of hyaluronic acids. The fat transfers consist of the patient’s own stem cells, which work best to create lasting results. More and more women are receiving these treatments to shape their vagina, creating an aesthetically appealing appearance.

Dr. Sherif Wakil stated that women in the Middle East also seek out vaginal bleaching. He stated that they don’t like the darker pigmentation in that intimate area. It is hot in the Middle East and the heat causes the genitalia to be hot, which causes the darker pigmentation. Also, wearing silky underwear causes hyperpigmentation. Dr. Wakil advises against silky underwear and suggests to wear underwear with cotton. He states that it is difficult to treat the vaginal hyperpigmentation because it can cause peeling, an infection, irritation, and itching and, because the treatment has to be mild, it takes longer to treat. Waxing also causes darkness on the vaginal area, as well as friction from legs rubbing together around the vaginal area. When bleaching the vaginal area for aesthetic appearances, the women need to take into the consideration the changes that need to be made to not aggravate it for reoccurring purposes.

During one of Dr. Sherif Wakil’s classes, the floor was open for questions. One of the Middle Eastern gynecologists asked him if the doctor needs to have consent from both the man and the woman to receive treatment. This made Dr. Wakil very upset. During the interview, when I asked him about this moment in the class, he was very agitated that people still think this way. He said that he has spoken in over 50 countries and this is the first time any doctor ever asked that question. He wants doctors to become more aware of treating the women as individuals, not needing permission from their husbands to receive treatment. Dr. Sherif Wakil is from Egypt and practices in London and is very aware of the stigmatization women have in regards to seeking independence from their husband. He hopes through time that more doctors will allow the women to seek assistance from them without fearing rejection.

Attending a conference in a country where customs are different from the American culture, I learned that there exists a stigmatization regarding vitiligo, where Americans see it as a skin condition and not a contagious infection. I also learned that even though Middle Eastern women may be covered in a different fashion from United States culture, they still seek to be aesthetically pleasing from head-to-toe.

Amra Lear has been licensed as a massage therapist since 1997 and a licensed aesthetician since 2005. She has worked in two luxury resort spas on the Las Vegas Strip since 1999. Lear is a nationally certified board therapeutic massage and bodywork CEU provider, where she trains other professionals in various massage modalities and develops spa treatments in both massage and aesthetics.