Clinical FeaturesDermatology

Discussing reproductive potential with transgender patients in Dermatology clinics

Dear Editor, Transgender people are individuals whose gender identity or gender expression is different from the gender they are assigned at birth. As of 2011, an estimated 0.3% of adults identified as transgender in the United States.1 This is likely reflected globally. Transgender people have their own set of complex medical issues, chief among them are a subset of dermatological issues. As such, as dermatologists, it is important that we not only recognise the specific dermatological needs of these patients, but also the nuances in their treatment and are competent in discussing these issues using appropriate terminology that puts our patients at ease.

We are seeing increasing numbers of patients in our dermatology clinics that identify as Transgender. Some of these patients have had gender affirming procedures. The use of teratogenic medications, while common place in dermatology, can create a nuanced issue when treating patients who identify as transgender, particularly trans-masculine patients (assigned Female at birth, identifies as Male). Discussions regarding reproductive potential have the capacity to enhance gender dysphoria and have previously been identified as triggering for patients.2

The use of neutral and inclusive terminology is important in creating an environment that is culturally welcoming to all. Making assumptions of gender identity, choice of pronoun or sexual identity can damage the rapport between the clinician and patient and should be avoided.1 It is important that providers use patient centred language, including their name and chosen pronouns, as well as their terms for their sexual orientation, gender identity, sexual behaviour and anatomy.3

A recent article in Pediatric Dermatology recommends at initial and subsequent clinic visits, an open discussion regarding the patients anatomy and pregnancy potential, as well as whether their current or future sexual practices could result in pregnancy ( i.e receptive vaginal penile intercourse), is necessary. This allows providers guide patients on appropriate methods of pregnancy prevention.4 It has also been recommended that counselling regarding pregnancy prevention should focus on the reproductive potential of the patient as opposed to their gender assigned at birth.2

An organ inventory has been recommended. This is a helpful tool for clinicians to identify patients of reproductive potential, however may also serve as a platform to discuss the need for regular pregnancy testing and/ or contraception. It has been advised to avoid words such as ‘breast’, ‘vagina’ or ‘penis’ and instead use words such as ‘chest’ and ‘genitalia’ to avoid triggering gender dysphoria.3 Transmasculine patients, assigned female at birth, who have a functioning uterus and ovaries, should still be considered as having reproductive potential, even if they are currently receiving testosterone therapy and are currently amenorrhoeic. However transmasculine patients who have undergone hysterectomy and/ or bilateral oophorectomy would not have reproductive potential. It is noteworthy, that the need for regular pregnancy tests may lead to increased gender dysphoria, particularly among transmasculine patients and this may need to be taken into consideration when discussing certain therapeutic options with patients, such as isotretinoin, where monthly pregnancy tests are required.

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