At the 17th ODAC Dermatology, Aesthetic and Surgical Conference held January 17-20, 2020 in Orlando, FL, Dr. Angelo Landriscina led a session on developing new approaches to caring for LGBTQ+ patients.
Next Steps correspondent Dr. Anna Chacon reports back on highlights and pearls from the session which covered the following:
- Why this topic?
- Updating Our Understanding of SGM Patients
- Caring for Transgender Patients
- Aesthetic Treatments for Transgender Patients
- Creating A Competent Clinical Environment
Why this topic?
It is difficult to determine how many people identify as LGTBQ+ in the United States. Right now, our best estimate is about 4% based on survey data. These patients tend to cluster into different areas, but it’s likely that you will see 2-3 patients per day who are a part of these communities.
Using the appropriate terminology is also key. There is a difference between sexual orientation and gender identity. Sexual orientation describes an individual’s emotional, romantic or sexual attraction to others while gender identity can be male, female or neither, and it can change over time.
What does LGTBQ+ stand for?
The acronym stands for lesbian, gay, bisexual, transgender, queer and questioning but can even be longer (LGBTQQ2SIAA)! There are other terminologies that can also be included such as intersex, gender fluid, and gender queer. Intersex describes: a variation in sex characteristics including chromosomes, gonads, or genitals that do not allow an individual to be distinctly identified as male or female. Gender fluid describes a person who doesn’t identify with a fixed gender at all times. And genderqueer is an umbrella term for gender identities that are not exclusively masculine or feminine identities which are thus outside of the gender binary and cisnormativity.
Queer is a blanket term that can describe all of these but has a loaded history since it used to be use as a slur. SGM stands for sexual and gender minority, which is an easy clinical and scientific term to use when talking about this population. While it is helpful to become familiar with the appropriate terminology, it is also important to be mindful of which particular terms to avoid when talking to patients such as: homosexual, sexual preference, “lifestyle,” and “sex change.”.
When it comes to pronouns, it is best to ask patients which they prefer. In situations where this may be unclear, the singular pronoun “they” may be your best friend – it was Merriam-Webster’s 2019 word of the year!
Additional tips for the dermatologist include being comfortable with not knowing everything, allowing your patients to define themselves, and recognizing that sexual orientation and gender identity are independent of each other.
Updating Our Understanding of SGM Patients
As physicians, it is important to update our understanding of SGM patients and their unique medical risks. In medical school, we are taught to associate SGM patients with medical conditions such as sexually transmitted infections or high-risk behaviors.
We must update our understanding since many decades have passed without a paradigm shift. The classical notion about treating SGM patients can seem redundant, since much of what we learn about SGM patients focuses on men who have sex with men (MSM) alone. Much of the new interest in our field focuses on transgender patients. Other populations such as women who have sex with women (WSW) are still neglected. Gaining knowledge on this subject allows us to provide better care to patients and see patients as a whole person. It also helps inform our differential diagnosis, allows us to see how certain risks or comorbidities may interact with dermatologic disease and enables us to play a role in preventive care.
SGM patients as a whole are more likely to suffer from mental illness and suicidality. Approximately 10-20% of LGB and 40% of transgender people will attempt suicide in their lifetime. They are also more likely to be homeless, have high rates of tobacco, alcohol, and illicit substance use; and more likely to have lower education, lower incomes, unemployment, food insecurity, and a lack of health insurance.
There are particular risks associated with men who have sex with men (MSM). 70% of new HIV infections in the US in 2014 were in MSM. Other sexually transmitted infections (STIs) are more prevalent in this population including: HSV2, HPV, gonorrhea, chlamydia; and hepatitis A, B and C. There have also been clusters of meningococcal meningitis, MRSA (methicillin-resistant Staphylococcus aureus), and HHV8 (human herpes virus 8) with a higher incidence of Kaposi sarcoma in both HIV+ and HIV- MSM.
MSM may also face an increased risk of skin cancer. MSM patients are more likely to have reported a history of skin cancer, more likely to used tanning beds, less likely to use protective clothing, but more likely to use sunscreen. There are also increased risks of body dysmorphia and eating disorders compared to non-SGM men.
Preventive care for MSM includes screening for HIV, syphilis, site-specific gonorrhea and chlamydia swabs based on sexual practices at least annually. If a patient is sexually active with multiple partners or has a partner who has multiple partners, screening should be done every 3-6 months.
PrEP refers to pre-exposure prophylaxis for HIV. FDA guidelines for this treatment include: MSM, heterosexual patients with multiple partners, intravenous drug users, and patients in serodiscordant couples. The treatment is comprised of emtricitabine and tenofovir which underwent FDA approval in 2012, is used daily, and in 2-1-1 dosing. When taken daily, it is greater than 90% effective in preventing HIV. Adverse effects include issues with renal function, osteopenia, and an uncharacterized rash. HIV and STI status should be assessed every 3 months while on this treatment.
WSW refers to women who have sex with women, an understudied population. These patients are less likely to use safer sex practices, perceive less need for screening, and are still at risk for HIV, HSV, HPV among other sexually transmitted infections. Women who have sex with both men and women have higher self-reported STI rates than women who have sex with men including chlamydia, HSV, and HPV. Preventive care in WSW should be the same as for women who have sex with men and includes regular pap tests and the HPV vaccine.
Transgender patients are also a patient population that is less studied. Male-to-female patients likely have similar risks as MSM, and their healthcare should be managed similarly.
Although it may seem like a lot of information was covered in this lecture, it is important to think about all of these factors in the clinical setting. These patients are more likely to have stressors or risk factors such as lack of insurance and homelessness, which may play a role when we are treating them as our patients.
Caring for Transgender Patients
After presenting a few patient cases, Dr. Landriscina covered the topic of gender dysphoria. Stress can be derived from an incongruence of gender identity and physical sex, can be related to societal attitudes about gender identity and can be treated via gender transition.
Regarding transgender healthcare for the dermatologist – many patients may undergo gender-affirming medical procedures and medical therapies and may seek your advice. It is important to note that no two patients are alike. The goal is to increase their quality of life and decrease their gender dysphoria. Cosmetic treatments have been shown to increase quality of life in these patients.
Female-to-male gender transition often includes cross sex hormone therapy which is usually intramuscular or transdermal testosterone, which can result in increase of facial and body hair, redistribution of fat, cessation of menses, and clitoral enlargement. Surgeries performed can range from mastectomies, nipple areola reduction, liposuction, hysterectomies, and oophorectomies. Genital reshaping procedures include metoidioplasty, phalloplasty, scrotoplasty, and urethral lengthening.
Dermatologic sequelae in female-to-male patients may result from hormone therapy and resemble the classic manifestations of androgen excess. Acne can be severe enough to warrant isotretinoin. Androgenetic alopecia can occur in up to 33% of patients, usually seen 2-5 years after initiation of hormone therapy; there is no consensus on treatment of hair loss as finasteride may block development of desired secondary sexual characteristics. A small case series showed no adverse effects from 1 mg daily of finasteride.
For male-to-female patients, hormonal therapy often involves estrogen (intramuscular, transdermal or oral); and anti-androgens such as spironolactone, finasteride, dutasteride and other treatments. Dermatologic sequelae in these patients includes melasma or asteatotic eczema in conjunction with estrogen therapy; recalcitrant facial or body hair in which eflornithine, laser hair reduction and electrolysis can be used. After vaginoplasty, these patients are still at risk for intravaginal hair growth, condylomas, and carcinomas. There are also risks associated with illicit filler injections including industrial silicone that may lead to foreign body granulomas, bacterial or atypical mycobacterial infections and lymphedema or scarring.
When prescribing treatments such as isotretinoin and using the IPledge system, the current recommendation is to register the patient as their sex assigned at birth. Advocacy initiatives are currently under way to attempt to change IPledge to better reflect patient’s varied gender identities. One proposed system would classify patients as “patients who can get pregnant” and “patients who cannot get pregnant.” Physicians should recognize that FTM patients on testosterone may still be able to get pregnant, so a thorough history is warranted before starting isotretinoin.
Aesthetic Treatments for Transgender Patients
Aesthetic treatments are an important tool because they can decrease gender dysphoria and improve quality of life. These aesthetic procedures are considered gender affirming, not cosmetic, and can augment the effects of hormonal therapy.
Regarding male-to-female patients, 45% of MTF patients prioritize facial aesthetics, and 77% have had a facial procedure. Meanwhile in FTM patients, 71% prioritize the chest area. There are special considerations regarding facial procedures – some masculinizing/feminizing characteristics can result from hormone therapy alone, and not every patient will want every existing procedure or to “pass.” Cultural differences must also be kept in mind. While surgery has been sought after by patients, injectables can also provide favorable results. Lastly, the ideal image is sometimes based on Caucasian ideals and the patient’s ethnic background and cultural differences should be taken into account.
When approaching aesthetic facial procedures, it is best to consider patient preferences, keep cultural differences in mind and take an inventory. While injectables may augment changes seen from hormone therapy, they will not change bone structures and patients may ultimately need surgical management to attain some of their goals.
Hair transplantation is also a surgical procedure that can be used in male-to-female or female-to-male patients. MTF patients can seek hairline lowering or a more feminine ovoid hairline. FTM patients can use it for beard growth or use topical minoxidil in this area. Scar reduction is also a consideration in FTM patients who have undergone chest reconstruction as a large portion of these patients will require scar revision. There are no studies of minimally invasive body contouring at this time in transgender patients.
Creating A Competent Clinical Environment
Creating a competent clinical environment is an important strategy for increasing inclusivity and providing the best care to SGM patients. Strategies for creating such an environment include appointing a point-person or several people in your practice to oversee LGTBQ+ matters, revising existing policies such as nondiscrimination policies to include SGM, engaging in community outreach and providing gender neutral restrooms. It is important to pursue LGTBQ+ focused employee training and making it routine for all.
It is also helpful to routinely collect data about sexual orientation and gender identity. It makes history-taking easy, helps to avoid assumptions, and shows patients that you value their identity. Research shows that patients are receptive to disclosing this information and collecting this data as part of their intake is patients’ preferred method of disclosure. Furthermore, it can expand our understanding of these communities through research. Examples of information to include are sexual orientation, self-described, sex assigned at birth, gender identity, and preferred names or pronouns.
Lastly, Dr. Landriscina’s recommendations as dermatologists for these patients are to keep learning – patients will appreciate your dedication.
Did you enjoy this post? Find more on LGBTQ+Care here.
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