Expert Roundtable: Ethical Issues in Acne Care for Transgender Patients

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In dermatology, ethical dilemmas may arise when providing acne care to transgender individuals, particularly female-to-male patients receiving testosterone treatment. <i>Credit:ISM</i>
In dermatology, ethical dilemmas may arise when providing acne care to transgender individuals, particularly female-to-male patients receiving testosterone treatment. Credit:ISM

As awareness of the transgender population has increased, there is a growing recognition of the unique healthcare needs of these individuals. While the emerging field of transgender medicine aims to address these issues, current disparities in care are substantial. In a survey of transgender and gender-nonconforming patients, 90% of respondents reported that they had faced one or more barriers to care, and 70% had experienced one or more forms of discrimination — most often a provider's lack of awareness of the patient's health needs.1

In dermatology, ethical dilemmas may arise when providing acne care to transgender individuals, particularly female-to-male patients receiving testosterone treatment. One study found that acne was a side effect of testosterone treatment in approximately 88% of patients within the first 6 months of therapy, while 93.9% of patients on long-term testosterone treatment (median, 10 years) had no or mild acne.2,3

Generally, appropriate “bedside manner in the treatment of [transgender patients] dictates the use of the name and personal pronoun that they choose, that any judgment of their transgender condition be avoided, and the recognition that examination of the thorax and chest for acne may be particularly embarrassing for them,” according to a paper published in May 2018 in Pediatric Dermatology.4

Findings support the effectiveness of isotretinoin as a treatment for severe testosterone-related acne in this population.2 However, a prescription for isotretinoin for transgender males presents challenges primarily related to the categorizations included in the iPLEDGE registration system and related educational materials for patients.2,5

To explore these issues and treatment implications for dermatologists, Dermatology Advisor spoke with 3 experts: Jules Lipoff, MD, assistant professor of clinical dermatology at the Perelman School of Medicine, University of Pennsylvania in Philadelphia; Allison R. Larson, MD, assistant professor of dermatology and assistant dean of academic affairs at Boston University School of Medicine in Massachusetts, and co-author of a 2016 paper5 on the topic; and Melissa Piliang, MD, FAAD, a dermatologist at Cleveland Clinic in Ohio.

Dermatology Advisor: What are some of the ethical challenges that dermatologists may encounter in treating transgender patients for acne, and how should these issues be addressed?

Dr Lipoff: For the most part, treating transgender patients for acne is straightforward and similar to treating any patient. Still, in female-to-male patients, their testosterone medication often is a major driver of their acne, so the acne can be challenging to control. One ethical quandary can arise in male transgender patients who are capable of getting pregnant — if we are to prescribe isotretinoin, the required iPLEDGE registration system currently still only lists categories for men and women who can or cannot get pregnant. So we would technically be required to list them as female and able to get pregnant, meaning they would have to get monthly pregnancy tests, even if they are not sexually active with men. A provider could theoretically list the patient as a male anyway and skip these tests, but the question arises of whether that is acceptable and whether such providers may be liable for any risks. 

Dr Larson: As physicians, nurse practitioners, and other healthcare providers, we want to ensure that the care we give is gender-affirming. With respect to acne, this involves creating a treatment plan that will not impede gender transition. Gender affirmation can also become challenging for transgender men, transgender women, and patients with non-binary gender identities with severe acne who decide — in conjunction with their provider — to take isotretinoin to help with their acne.

Treating such patients while operating within the bounds of the iPLEDGE system requires a sensitive conversation with the patient. I talk with my transgender patients who are preparing to begin isotretinoin about the steps that will be involved for iPLEDGE and the gender terminology they are going to see in print and online in conjunction with this program. I explain how iPLEDGE defines abstinence. I perform urine pregnancy tests in-office to minimize the embarrassment of going to a facility laboratory for a urine pregnancy test, and I also offer the option of monthly blood-based pregnancy tests at a laboratory if the patient feels this would be more gender-affirming.

Dr Piliang: Treating acne in transgender patients presents several challenges to dermatologists, mostly revolving around the hormonal effects of medications for gender transition and pregnancy risk. Women transitioning to men take androgens in order to develop male physiologic characteristics such as facial hair, a deeper voice, and a more muscular physique. A frequent unintended adverse event with these treatments is acne, which may be quite severe and treatment-resistant. Patients and dermatologists are faced with an ethical dilemma of continuing a needed, but acne-inducing medication and treating the patient's acne. While first-line therapies should be attempted and are successful in some patients, many patients will ultimately require isotretinoin. In contrast, the hormonal regimen used for male-to-female transition includes estrogen and anti-androgens, such as spironolactone, which may help acne.

The use of isotretinoin in patients undergoing gender transition and transgender patients is especially challenging with respect to the iPLEDGE system. Similar concerns about potential pregnancy and risk for a developing fetus can occur with the use of spironolactone. Because sprinolactone is an anti-androgen, it would not be a good choice for treating transgender male patients.

Dermatology Advisor: What are additional treatment implications or other considerations for clinicians?

Dr Lipoff: With any patient it is important to consider how acne and related problems may affect quality of life and how a person presents themselves to the world. Every patient is an individual with different expectations and every patient should be treated based on those expectations. In dermatology, we truly have an opportunity to help patients present themselves the way they see themselves.

Dr Piliang: It is important to respect patients' wishes for their gender designation in our charting documentation and in any documentation of sex or gender, as the iPLEDGE system requires patients to be categorized by their sex at birth, not their identified gender.

Dermatology Advisor: What should be next steps in this area in terms of research or otherwise?               

Dr Lipoff: We should continue to look for new treatments for acne in general. In transgender patients on hormonal therapies, we can investigate how to avoid the negative adverse events associated with these therapies (eg, acne) while still gaining the intended transgender effects.

Dr Larson: I am pleased to report that the American Academy of Dermatology has established a Lesbian Gay Bisexual and Transgender/Sexual and Gender Minority (LGBT/SGM) health task force. There is more research needed on the time course of acne in transgender men receiving testosterone therapy and on which therapies are more or less successful in this patient population, both in the short- and and long-term.

Dr Piliang: It is important to advocate for the rights of transgender patients to receive isotretinoin and to be allowed to accurately reflect their gender and child-bearing potential. This requires engagement and communication between the US Food and Drug Administration (FDA), iPLEDGE, dermatologists, the American Medical Association (AMA), and patients. 

References

  1. Lambda Legal. When health care isn't caring: transgender and gender-nonconforming people. Results from Lambda Legal's Health Care Fairness Survey. www.lambdalegal.org/sites/default/files/publications/downloads/whcic-insert_transgender-and-gender-nonconforming-people.pdf Accessed June 18, 2018
  2. Yeung HChen SCKatz KAStoff BK. Prescribing isotretinoin in the United States for transgender individuals: Ethical considerations.J Am Acad Dermatol. 2016;75(3):648-651.
  3. Wierckx KVan de Peer FVerhaeghe E, et al. Short- and long-term clinical skin effects of testosterone treatment in trans men.J Sex Med. 2014; 11(1):222-229.
  4. Campos-Muñoz LLópez-De Lara DRodríguez-Rojo MLConde-Taboada ALópez-Bran E. Transgender adolescents and acne: A cases series.Pediatr Dermatol. 2018;35(3):e155-e158.
  5. Mundluru SNSafer JDLarson AR. Unforeseen ethical challenges for isotretinoin treatment in transgender patients. Int J Womens Dermatol. 2016;2(2):46-48.
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