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Dermatologists are uniquely suited to help sexual-, gender-minority patients


 

EXPERT ANALYSIS FROM ODAC 2020

– There is a deficit in scientific research for sexual- and gender-minority (SGM) patients in dermatology, despite dermatologists being uniquely suited to help these patients, Angelo Landriscina, MD, said at the ODAC Dermatology, Aesthetic, & Clinical Conference.

Dr. Angelo Landriscina

“Our knowledge lagging behind is really to our own detriment,” said Dr. Landriscina, chief resident of dermatology at George Washington University, Washington. “The unique comorbidities and lived experiences of queer patients can impact their dermatologic disease. In addition to that, we are in a really unique position to provide life-changing care for these patients.”

The topic of dermatologic care for SGM patients has been discussed with interest in the dermatology community, but it has not been well studied. In one of two papers recently published in Pediatric Dermatology, Markus D. Boos, MD, PhD, from the University of Washington, Seattle, and Seattle Children’s Hospital, and coauthors noted that there is a particular knowledge gap in how to care for SGM pediatric and adolescent patients (Pediatr Dermatol. 2019 Sep;36[5]:581-6; 587-93).

In his presentation, Dr. Landriscina outlined the differences between sexual orientation – an emotional, romantic, or sexual attraction to others – and gender identity, or how one perceives their own gender. Lesbian, gay, transgender, and queer/questioning are classical definitions, but SGM patients may also self-identify in any number of other ways. Some SGM patients may identify as gender-fluid or nonbinary, while genderqueer is an umbrella term for individuals who don’t identify with typical gender roles. On the topic of pronouns, asking SGM patients how they want to be referred to is ideal, but the singular they is considered a gender-neutral term that should work for most situations.

There are also terms to avoid: “Homosexual” may be acceptable to some SGM patients, but is from an era when same-sex attraction was pathologized; “sexual preference” characterizes sexuality as a choice; the term “lifestyle” perpetuates the idea that all SGM patients are the same; and referring to transgender patients as "pre-op" or "post-op" is problematic as these terms imply that transgender identity is defined by a medical transition. Using transgender or gay as a noun, or the word transsexual, is offensive and shouldn’t be used at all, according to Dr. Landriscina.

As these terms continue to change and be redefined, dermatologists are likely to encounter terms they are unfamiliar with in the clinic, but he emphasized that attendees need not know every term to care for these patients. “The easiest way to be right in all of these situations is to let your patients define themselves,” he said, but noted that “assumptions are your worst enemy. You’re going to have to ask the hard questions.”

Updating understanding of SGM patients

Much of the medical community’s understanding of SGM patients hasn’t been updated in decades, Dr. Landriscina said. For example, medical school students typically learn about SGM risk factors that only apply to men who have sex with men (MSM), but there is new interest in caring for transgender patients within dermatology. The focus on classical notions for treating MSM can be reductive, Dr. Landriscina explained. “It boils a whole community of people down to one disease process. I think that we need to expand the thought that there are other associations here. There are other risks these patients face.”

In contrast, dermatologists who strive to understand their patients can better see them as a whole person, can engage in a better differential diagnosis, are aware of the current comorbidities SGM patients face that affect dermatologic disease, and can even work with the patient toward preventative care.

“It’s been decades since we’ve had a paradigm shift about this, and I think it’s time,” he said.

Overall, SGM patients have a higher likelihood of suffering from mental illness and suicidal ideation, with 10%-20% of lesbian, gay, and bisexual patients attempting suicide. Gender-minority patients have a significantly higher rate of attempting suicide at 40%. SGM patients are also more likely to be homeless and uninsured, and have the highest rates of tobacco, alcohol, and illicit drug use. In the SGM population, there is a higher likelihood of being victimized, and discriminated against, with this risk being much higher in transgender patients.

For MSM, there is a high risk of HIV and other STIs such as herpes simplex virus type 2 (HSV2), human papillomavirus (HPV), gonorrhea, and chlamydia, Dr. Landriscina said. They are also at risk for hepatitis A, B, and C; clusters of meningococcal meningitis; and human herpes virus 8. While MSM are more likely to use sunscreen, they also are more likely to use tanning beds and not wear protective clothing outdoors, and are at a greater risk of skin cancer. The risks of body dysmorphia and eating disorders are also increased for MSM.

While there is not as much research on risk factors for women who have sex with women (WSW), they are still at risk for HIV, HSV, and HPV and are less likely to engage in safe sex practices. For women who have sex with both men and other women, there is an even greater risk of STIs. While WSW are more likely to perceive less need for screening, they should be given the same screening as all other women, and dermatologists can help by ensuring these patients are connected with primary care providers, he said.

Dermatologic sequelae for transgender patients

For patients who transition from male to female, there is little information on their sexual risk from studies, but their care should be managed similarly to MSM, Dr. Landriscina said. When seeing transgender patients, dermatologists should be aware of issues of gender dysphoria, but not offer any intervention without first having a conversation about the patient’s hopes and goals. “Not every patient will have the means or desire to have everything that you can offer,” he said.

For patients who choose to undergo a female-to-male transition, dermatological sequelae may include classical manifestations of androgen excess from hormone therapy such as acne and androgenic alopecia; acne, miliaria, tinea corporis, contact dermatitis from chest binding; and surgical scars and keloids. For acne, isotretinoin is an option if a case is severe, but dermatologists should be aware these patients may still be able to become pregnant. There is no consensus on treatment for androgenic alopecia, but use of finasteride might block wanted secondary sex characteristics, Dr. Landriscina noted.

Patients who undergo a male-to-female transition may develop melasma or asteatotic eczema while receiving estrogen therapy; unwanted facial or body hair; and complications from illicit “filler” injections that may cause foreign-body granulomas, bacterial or atypical mycobacterial infection, lymphedema, and scarring.

Transgender patients may choose to undergo aesthetic treatments that can affirm their gender and decrease their gender dysphoria, augment the effects of hormone therapy and gender-confirmation surgery, and improve their quality of life. “While this has classically fallen under the purview of plastic surgery, I feel like we’re uniquely positioned to provide really life-changing aesthetic services to these patients,” Dr. Landriscina said.

Creating an inclusive environment is key to successfully caring for SGM patients. Any practice policies should have SGM-inclusive language, employees should receive mandatory LGBTQ+ focused training, and a point person should oversee LGBTQ+ matters, according to the Joint Commission’s LGBT Guide. Practices should also begin collecting data on sexual orientation and gender identity, which may help patients who are reluctant to vocally disclose their sexual orientation and gender identity and expand understanding of SGM patients. “Before you even walk into that visit, you know what the patient’s identity is, how they want to be addressed,” said Dr. Landriscina. “It also shows patients that you value what their identities are and that you’re competent in taking care of them.”

Dr. Landriscina encouraged attendees to take the information they learned in the session and “run with it.”

“Go for it. Keep learning,” he said. “There’s more about this topic than I even had the chance to include. Your patients are going to appreciate your dedication to them.”

Dr. Adam Friedman

In an interview, Adam Friedman, MD, professor and interim chair of dermatology at George Washington University and medical director of ODAC, acknowledged the large gaps in care for SGM patients and the unique role dermatologists can play in their care, both in terms of medical and surgical procedures.

“There are specific considerations that we as dermatologists need to think about in terms of just quality of life, potentially mental disease, homelessness, access to care. I think if we consider the whole picture, we can not only provide dermatologic care, but maybe serve as a pivot point to direct them to other specialists, and other physicians, and even nonphysicians who play a role in all facets of life to really get these individuals all the care, in broader senses, that they need,” he said.

Dr. Landriscina reported no relevant conflicts of interest.

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