One of the most vulnerable populations among both teenagers and adults today is the LGBTQ community. An estimate of the LGBTQ population is difficult to solidify, but based on survey data it is estimated that sexual and gender minority individuals collectively represent four percent of the general population. The LGBTQ community is more likely to experience both dysphoria and discrimination, and there is an increased rate of depression and suicidality in this population. Although acne is not unique to LGBTQ+ patients, it is important to understand the physical and psychosocial burden associated with acne in sexual and gender minority individuals and employ a unique multidisciplinary approach to their management.
At the 2020 George Washington Virtual Appraisal of Advances in Acne Conference on July 30th, Angelo Landriscina, M.D., who is a Dermatologist, Scientific Researcher, Medical Writer, and Blogger in the New York City Area, gave a lecture entitled, “Acne in the LGBTQ+ Population,” which provided numerous, extremely valuable pearls to employ when treating acne in sexual and gender minority patients. These evidence-based statistics and tips are eye-opening and invaluable to all providers in the dermatologic community.
This post will provide insights into the individualized approach to acne management in sexual and gender minority patients highlighted in Dr. Landriscina’s lecture and provide the following educational material:
- Comprehension of the psychosocial burden of LGBTQ+ teens and adults
- An overview of transgender healthcare for the dermatologist
- An understanding of gender-affirming medical treatments for transfeminine and transmasculine patients
- The association between gender-affirming testosterone therapy and acne
- Individually tailored acne vulgaris management in sexual and gender minority patients
- Insight into the current iPledge policies towards gender and sexual minority patients
- Counseling techniques for acne patients within the LBGTQ+ population
Sexual and gender minority patients may present with additional psychosocial burdens that the physician must be aware of
LGBTQ+ patients are more likely to suffer from victimization and discrimination in comparison to the general patient population. This is especially true of gender minority patients. Furthermore, sexual and gender minority individuals are more likely to suffer from mental illness and attempt suicide. Approximately 10-20% of LGBTQ+ people will attempt suicide, especially during their formative teenage years. There are also higher rates of tobacco, alcohol, and illicit drug use in this population.
Sexual and gender minority patients may present with additional socioeconomic barriers to their medical care
LGBTQ+ patients are more likely to be unemployed, uninsured, food insecure, and live below the poverty line. This population is also more likely to be classified as homeless. Thus, these patients may have insurmountable financial burdens when it comes to seeking medical care for acne or any other illness.
Acne may amplify these burdens as both acne and sexual and gender minority status are both associated with depression and suicidality
Regardless of sexual orientation and gender identity, acne is correlated with depression and suicidal ideation. However, studies have shown that this risk is amplified in the LGBTQ+ population. One such study revealed that the rate of suicidal ideation in the heterosexual population is increased by around 1.5% in those with acne (7.8% in acne patients versus 5.3% in non-acne patients). This risk exponentially increased in sexual minority patients, as acne increased the suicidal ideation rate 20.1% (35.4% in acne patients versus 15.3% in non-acne patients). Thus according to Dr. Landriscina:
Dr. Landriscina further emphasized the importance of comprehending transgender healthcare.
This starts with understanding the meaning of gender-dysphoria – the stress derived from the incongruence of an individual’s gender identity and physical sex assigned at birth. Though gender dysphoria is experienced differently by different patients and no two patients are alike, many of these patients may undergo gender-affirming procedures and medical treatments. This often requires a multispecialty approach involving the primary care provider, surgeons, endocrinologists, dermatologists, and other specialists. Dermatologists may support transgender patients by managing adverse cutaneous sequelae, such as acne, associated with gender-affirming procedures and treatments. Dr. Landriscina further advocates for the creation of a specialized field of dermatology – “Supportive Gender Affirming Dermatology”. With dermatologic support, these patients may achieve better outcomes and experience decreased gender dysphoria.
So what are the specific medical procedures and therapies than transfeminine and transmasculine individuals undergo? And how are they correlated with acne vulgaris?
When considering gender-affirming treatments tailored to the transfeminine patient, hormone therapy is often employed. These hormonal therapies may include estrogens and anti-androgens, such as Spironolactone, Finasteride, and Dutasteride. These medications collectively reduce body and facial hair and promote breast development. Cutaneous sequelae of these medications include melasma and asteatotic eczema. On a positive note, these hormonal therapies generally lead to a reduction in sebum production and a decrease in acne.
Gender-affirming treatments for trans masculine patients similarly include cross-sex-hormone therapy utilizing intramuscular or transdermal testosterone. This promotes the development of desired secondary sexual characteristics including increased facial and body hair, redistribution of fat, and cessation of menses. Despite these desired effects, many undesirable cutaneous effects often occur including increased sebaceous gland diameter and sebum production, and keratinocyte hyperproliferation resulting in severe acne.
While we don’t have extensive data about acne in gender minority patients, risk factors for acne development in transmasculine patients seem to include higher BMI and testosterone level > 630 ng/dL. New or worsening acne typically develops within four to six months of starting testosterone therapy and can continue to evolve in severity over two years.
How do we manage acne in transmasculine patients undergoing testosterone therapy?
Despite the lack of guidelines for acne management in transmasculine patients, therapies generally include mainstays of acne treatment such as topical retinoids and oral antibiotics. It is critical to avoid hormonally active agents such as oral contraceptives or spironolactone that may be counterproductive to the desired hormone effects of testosterone. In cases of moderate to severe acne vulgaris, oral isotretinoin is often required.
When considering isotretinoin and its associated teratogenicity, we need to really consider how to counsel sexual and gender minority patients
Amenorrhea typically occurs within 6 months of initiating testosterone therapy. Despite this cessation of menstruation, testosterone therapy alone is not sufficient to prevent pregnancy. In fact, up to one-quarter of pregnancies seen in transmasculine patients are unplanned. It is important to take a full medical history, however, because some transmasculine patients choose to undergo hysterectomy. A discussion of reproductive potential and sexual history on an individual basis is critical prior to initiating isotretinoin. Furthermore, Dr. Landriscina suggested that it is important to consider the definition of abstinence and explain that abstinence is considered nonparticipation in any sexual activity that may lead to pregnancy.
How does iPledge screen and counsel sexual and gender minority patients?
Patients are required to register for iPledge as the sex they are assigned at birth, regardless of their gender identity. This may lead to psychological distress and induce gender dysphoria. Ensslin et al. revealed that 50 percent of dermatologists have encountered issues in registering gender minority patients in iPledge and 11.8% of dermatologists have ultimately chosen a different course of treatment due to this issue.
Despite the limitations of the iPledge system concerning a lack of gender-neutral classification, it is important for dermatologists to be sensitive, supportive, and gender-affirming. Noteworthy, 89.4% of dermatologists surveyed believe iPledge categories should be gender-neutral.
Collecting data about sexual orientation and gender identity is very important!
Collecting data about sexual orientation and gender identity is important to enhance the patient-physician relationship. Research shows that patients are receptive to disclosing this information and that their preferred method of data collection is via intake forms. This also shows patients that you value their identity as an individual, and creates opportunities for much-needed research about sexual and gender minority patients.
An ideal intake form would include the following information:
- Sexual orientation, self-described
- Sex assigned at birth
- Gender identity
- Preferred names and pronouns
Thank you, Dr. Landriscina, for a mentally stimulating and amazing insight into the current landscape on acne management in the LGBTQ population!
This information was presented by Dr. Angelo Landriscina at the GW Virtual Appraisal of Advances in Acne Conference held July 30th, 2020. The above highlights were compiled and written by Andrea Waldman, MD – Dermatologist and Pediatrician and Current Pediatric Dermatology Fellow at Columbia University Medical Center and New York Presbyterian Hospital
Did you enjoy this article? Find more on LGBTQ+ Care here.