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Published in final edited form as: Dermatol Clin. 2019 Nov 26;38(2):219–226. doi: 10.1016/j.det.2019.10.006

Acne and the Lesbian, Gay, Bisexual, or Transgender Teenager

Laura Ragmanauskaite 1, Benjamin Kahn 1, Bao Chau Ly 1, Howa Yeung 1
PMCID: PMC7080311  NIHMSID: NIHMS1544497  PMID: 32115131

Introduction

Acne vulgaris affects approximately 85% of adolescents.1 For sexual and gender minority teenagers, management of acne could be more challenging. Despite multiple well-established clinical practice guidelines on acne management from the American Academy of Dermatology and the American Acne and Rosacea Society, there is little guidance on the specific best practices of acne care for sexual and gender minority (SGM) adolescent patients.2,3 In this article, we will review the current literature pertaining to comprehensive acne care for SGM adolescents. First, comprehensive care for moderate-to-severe acne in sexual and gender minority adolescents should include culturally competent sexual health and contraceptive discussion.4 Second, dermatologists should consider psychosocial factors and mental health issues such as depression and suicidal ideation in sexual and gender minority teenagers with acne.5,6 Lastly, gender-affirming hormone therapies in transgender and gender nonbinary teenagers specifically impacts acne presentation, treatment, and prognosis.

Discussions of Sexual Behaviors and Contraception in Acne Care

Sexual and gender minority (SGM) is an umbrella term encompassing “lesbian, gay, bisexual, and transgender populations as well as those whose sexual orientation, gender identity and expressions, or reproductive development varies from traditional, societal, cultural, or physiological norms.”7 Clinicians should become familiar with relevant terminology and health issues to become culturally competent with caring for SGM patients.8–10 Using patient-preferred language - including names, pronouns, and any terms for their sexual orientation, gender identity, sexual behavior, or anatomy - is crucial in building therapeutic rapport.8–10

This is especially important in the context of moderate-to-severe acne treatment. Selection of acne treatments in SGM patients largely follow the recommendations from current clinical practice guidelines.2,3 In many cases of moderate-to-severe acne, oral medications such as combination oral contraceptives, as well as teratogenic drugs such as tetracyclines or isotretinoin are required.3 Specific consideration regarding sexual behaviors should be considered in all patients with reproductive potential, including postmenarchal SGM patients with functional female reproductive organs. Since sexual orientation and behaviors may be fluid, frank discussions of sexual behaviors, safer sex practices, and reliable contraception are crucial.

To set the stage for normalized discussions of sex, gender, and sexual health with both SGM and non-SGM adolescents, it is crucial for clinicians to have a working knowledge of the clinical and medicolegal aspects of consent and confidentiality in minors.11,12 Adolescents - particularly those at high risk of unintended pregnancy such as SGM youth - often cite confidentiality concerns as the reason to forgo health care, let alone sexual health and contraceptive care.13,14 While the U.S. Health Insurance Portability and Accountability Act (HIPAA) law allows parental access to the minor’s health records, a minor can consent to confidential sexual health care under appropriate state laws or if the parent agrees that the minor may have confidential care.15 Clinicians should become familiar with state-specific laws regarding contraceptive services. As of April 1, 2019, 21 states and the District of Columbia explicitly allow all minors to access contraception while 25 states affirm minor consent under specific circumstances based on age, marital status, or pregnancy status.16 Moreover, HIPAA law also allows the clinician to exercise professional judgment to deny parental access to a minor’s protected health information.12

Confidentiality should be addressed with the adolescent and parents at the initial visit, as many teens are unaware of the availability of confidential care. 17 The American Academy of Pediatrics recommends clinicians have an office policy that explicitly describes available confidential services and to discuss and document confidentiality with all parents and adolescents.12 Discussion of care, both with the parents present, as well as reviewing with the adolescent patient alone, is an important step to encourage honest discussions of sexual health and contraception as relevant to acne care. Studies have demonstrated that discussion of sensitive health topics has a positive impact on youth perceptions of care provided.18 This is especially important for SGM youth, who also are subject to lack of healthcare access, advocacy, and physician advice.19 Dermatologists must therefore take on the important role of patient educator and advocate, beyond just taking an appropriate sexual health history, contraceptive counseling, and providing contraceptive access.

Clinicians should also inquire about sexual orientation, gender identity, and sexual behaviors when treating patients with moderate-to-severe acne. Without specifically addressing these factors, clinicians may be unaware of their adolescent patients’ SGM status, despite its clinical relevance to acne care. A patient’s sexual history may be complicated and require further questioning for the purpose of better acne care and counseling. For example, an adolescent female identifying as a lesbian may have current sexual encounters with women only, but had prior sexual encounters with men. A second example is a masculine-presenting patient with severe acne who identifies as non-binary, was assigned female at birth, and may be sexually active with both men and women. These scenarios would require different contraceptive discussions prior to starting potentially teratogenic acne medications.

Specific and unambiguous discussions about safe sex practices and contraception are required due to varying health literacy among adolescents.20 Misconception of pregnancy potential and contraceptive efficacy among all adolescents is common.21 In a survey of 2,314 “millennials” Americans born between the years 1980 and 2000, 19% received sex education classes in high school only and not middle school, and 23% did not have any classes in middle or high school at all.22 Only 12% received sex education inclusive of same-sex relationships.22 In addition, prior studies suggested that adolescents who report practicing abstinence may actually engage in penis-vagina sexual intercourse on occasion.23 This implies that strict adherence to abstinence while taking isotretinoin may be difficult, particularly for those who have previously been sexually active. One study demonstrated that 19% of previously sexually active adult women, of whom 95% self-identified as heterosexual and chose abstinence as their primary contraception, admitted to having sexual intercourse during isotretinoin treatment. Furthermore, 31% of women who selected 2 forms of contraception had sex at least once without using both forms of contraception.24 Therefore, prior to starting oral treatments for moderate to severe acne in women, unless the patient has never been sexually active with men, discussion of contraception will be crucial to prevent potential teratogenicity.

Clinicians should also be aware that the normal development of sexual identity may vary among adolescents. For example, awareness of sexual attraction may begin around an average age of 9–10, while self-labeling as lesbian, gay, or bisexual may follow at an average of age 16.7 In addition to age variance, acceptance and disclosure of same-sex orientation, gender identity, and first sexual experience may vary widely.7 Widespread stigma and discrimination in healthcare settings may further complicate acceptance and disclosure ages for SGM youth.8,25 Therefore, it is important for clinicians to create a welcoming and non-judgmental environment that facilitates comprehensive acne care.

Psychosocial Impact of Acne in SGM Patients

Among teenagers, acne is associated with lower levels of self-esteem and higher levels of depression and suicidal ideation.5 Acne may lead to withdrawal from social activities and relationships.26 Acne may be associated with increased mental health-related hospitalizations and associated costs among patients with mental health diagnoses.27

The psychosocial effects of acne may be compounded in SGM patients, who have higher baseline risks of mental health issues compared to heterosexual peers.28 A national cross-sectional study of 4,094 heterosexual and 564 sexual minority young adults aged 18–28 years showed that acne and sexual minority status are both associated with depression and suicidal ideation. The reported odds of suicidal ideation within the past 12 months associated with acne is higher for sexual minorities (35.4% with acne vs. 15.3% without acne), as compared with heterosexuals (7.8% with acne vs. 5.3% without acne; P for interaction between acne and sexual minority status = 0.04).6 Since the quality of life impact of acne often does not correlate with objective measures of acne severity, it is important for dermatologists to routinely inquire and address the negative psychosocial impact of acne in SGM teenagers.29,30

Dermatologists should incorporate discussion of mental health impact of acne for SGM teens taking isotretinoin for mental health issues - particularly in the context of isotretinoin treatment for severe, nodular, or recalcitrant acne.28 While the research linking isotretinoin and depression and suicidal ideation has been controversial, dermatologist should be vigilant in screening for depression, given that the SGM patient population is already at an increased risk for mental health comorbidities.31“34 While noting that a history of mental health disorder is a relative contraindication for isotretinoin treatment, avoiding isotretinoin treatment summarily in this population deprives patients from effective treatment of acne and its negative effects on mental health. The Patient Health Questionnaire-9 has been used to screen for depression in both adult and adolescent patients. For adolescents aged 13-17 years, a PHQ-9 score of ≥11 has a sensitivity of 89.5% and a specificity of 77.5% for detecting major depression by DSM-IV criteria.35 The PHQ-9 has been advocated for use in screening for active depression and suicidal ideation at every visit prior to, during and after isotretinoin treatment.36 Recent meta-analyses have concluded isotretinoin treatment may improve symptoms of depression in patients with severe acne.33,34 It may also unduly create disparities in acne care access in SGM youth. Instead, dermatologists can facilitate both acne and mental health care access by providing routine screening and expediting referral to mental health professionals.

Acne in the Context of Gender-Affirming Treatment

Gender dysphoria is defined as significant distress due to the marked incongruence between someone’s expressed or experienced gender (gender identity) and one’s sex assigned at birth based on reproductive organs.1,37 Transgender and gender nonbinary patients often suffer the effects of gender dysphoria and require gender-affirming treatments, which may include hormonal therapy. Dermatologists should understand gender-affirming therapies such as “puberty blockers” and cross-sex hormone therapies as they have important implications on acne treatment and prognosis.

Puberty Blockers

Endogenous pubertal development may trigger or worsen gender dysphoria in transgender and gender nonbinary youth.1,29 Acne also occurs during the onset of puberty and may therefore worsen gender dysphoria. To prevent irreversible development of secondary sex characteristics and other phenotypic changes incongruent with an individual’s gender identity, the Endocrine Society and the World Professional Association for Transgender Health recommend puberty hormone suppression, or “puberty blockers.” These treatments include gonadotropin-releasing hormone agonists such as leuprolide injection or subcutaneous histrelin.38,39 Notably, gonadotropin-releasing hormone agonists have been used to treat acne and hirsutism in adult populations.40 The use of puberty blockers in transgender teenagers has increased drastically with the average age of therapy initiation starting around 14 years old.41 This trend will likely continue as insurance companies change their policies to be more inclusive of transgender medical needs.42 As such, peripubertal adolescents with acne and gender dysphoria should be referred to pediatric endocrinologists for consideration of puberty suppression and a discussion of gender-affirming therapy, in addition to guideline-based treatment of acne.

Testosterone Therapy

Current guidelines recommend gender-affirming hormones, such as testosterone therapy, for adolescent patients with persistent gender dysphoria and the capacity to provide informed consent, usually by the age of 16.39 Testosterone therapy is a common treatment for transgender males, or biological females who identify as male, that induces the development of secondary male sex characteristics. However, the Endocrine Society guidelines recommend that “clinicians evaluate and address medical conditions [such as acne] that can be exacerbated by hormone depletion and treatment with sex hormones of the affirmed gender before beginning treatment.”39

It is well known that the pathogenesis of acne is multifactorial, involving hormonal regulation, hyperkeratinization, increased sebum production, Propionibacterium acnes colonization, genetics, and environmental factors. 43,44 5α-reductase and 17β-hydroxy steroid dehydrogenase work to balance testosterone and dihydrotestosterone (DHT) production within sebaceous glands.45 Testosterone and DHT bind to androgen receptors on sebaceous cells which increases sebaceous gland diameter and sebum production.46 Increased activity of certain 5α-reductase isoforms is also associated with the increased keratinocyte hyperproliferation and formation microcomedones. Androgens create excess keratinization and increased sebum production that favor acne development.47

As a result, transmasculine patients who start testosterone therapy often develop or have worsening acne.8 While there is limited data on the natural history of acne in adolescents, existing studies in adults provide some evidence showing that acne develops within 4–6 months of testosterone initiation and may continue to evolve within the first two years.48 A prospective study of 20 transmasculine patients found both facial and back/chest acne increased in prevalence over the first six months of testosterone therapy, from 35% to 82% and 15% to 88%, respectively.49 55% of patients had facial acne and 50% of patients had chest/back acne after one year of testosterone therapy. Acne symptoms were typically mild with only 20% classified as moderate. A cross-sectional study of 50 transgender males averaging 10 years of testosterone therapy found that 70% had persistent acne symptoms. A recent study of 55 transmasculine patients on ≥2 years of testosterone therapy found the incidence of new onset acne to be 38%.50 Incidence of acne was correlated with serum testosterone levels >630 ng/dL.50 Another prospective study of 17 transgender males beginning hormone therapy found that more than 50% developed facial and back acne after 4 months of treatment.51 Back acne was more common and severe than facial acne. This pattern follows the typical acne distribution found among cisgender males.52 Current guidelines suggest hormone providers to assess patients every three months for adverse effects, including acne.53

There is no evidence-based guideline on the best practices for treating hormonal acne in the context of testosterone therapy. Clinicians currently rely on the general guidelines developed for cisgender populations.2,8 Some common acne treatments, such as hormone antagonists, may not be appropriate for transgender patients.54 However, given the known effect of testosterone on comedo formation, topical and/or systemic retinoids are crucial in addressing the first step of acne development.

Isotretinoin Treatment Considerations

While some patients on exogenous testosterone have improvement of their acne over the first 2 years, some develop severe, nodular, or recalcitrant acne that require oral isotretinoin. 55,56 Isotretinoin does not interfere with exogenous testosterone therapy but it does pose several unique challenges for transgender patients. Isotretinoin may be associated with delayed wound healing that persists for 6–12 months after its discontinuation.57 Patients planning to undergo gender-affirming surgeries should be aware of this potential side effect as it could delay their transition or affect the aesthetic results from their surgery. Dermatologists considering isotretinoin should discuss the patient’s goals and plans regarding any surgical procedures. Additionally, while parental consent may be waived in the context of sexual health, parental consent is required for isotretinoin treatment in minors.58,59

The teratogenic side effects of isotretinoin create additional treatment considerations for transgender patients. Patients’ sexual behaviors, gender identity, and history of gender-affirming therapy affect their risk for pregnancy and potential need for contraception. Some transmasculine patients may have had a hysterectomy and/or bilateral oophorectomy as part of gender-affirming surgical treatment and do not have the potential for pregnancy. On the other hand, a transmasculine person with a functional uterus and ovaries still has pregnancy potential if he engages in penis-vagina sexual intercourse with males, even if he were receiving testosterone therapy and were amenorrheic.60 Such complicated sexual histories must be elicited for appropriate counseling and enrollment in the iPledge program, as detailed below.

The United States Food and Drug Administration currently requires all patients initiating or receiving isotretinoin to participate in iPLEDGE, a registry aimed at preventing isotretinoin-exposed pregnancy.32 When working with LGBTQ acne patients, clinicians must help select the appropriate contraceptive options within iPLEDGE, keeping in mind the patient’s current or future sexual activity and reproductive potential. For instance, iPLEDGE allows female patients to select complete abstinence with men as a reliable contraceptive method. Transmasculine patients and cisgender lesbian patients who have reproductive potential, who are exclusively sexually active with cisgender women and do not have penis-vagina intercourse, may also select abstinence as a contraceptive method. Nevertheless, patients who cannot commit to complete abstinence from penis-vagina intercourse and have not undergone bottom surgeries (i.e. phalloplasty and metoidioplasty) will require two forms of reliable contraception.24

For transmasculine patients interested in oral contraception, progestin-based long-acting reversible contraception is indicated and does not interfere with testosterone therapy.61 Furthermore, intrauterine devices (IUD) with progestins containing levonorgestrel, intradermal etonogestrel implants, or depot medroxyprogesterone acetate injections provide the additional gender-affirming benefits of decreased menstrual bleeding and/or induction of amenorrhea in transmasculine or nonbinary adolescents.62 Progesterone-only pills or exogenous testosterone alone do not meet current iPLEDGE guidelines on contraception. While combination oral contraceptive pills may be used, many patients prefer to avoid estrogens given potential concern about feminizing effects that may be counterproductive to their transition goals.62 Multidisciplinary care with knowledgeable family planning providers will be essential to ensure appropriate provision of contraceptive care.

Dermatologists should also be aware that the language and pregnancy prevention guidelines in iPLEDGE were developed for cisgender women. iPLEDGE requires patients to gender-identify based upon their sex at birth.58,60,63 Transgender and gender nonbinary patients assigned female at birth are required to sign documentation that identifies them as “female patients who can get pregnant.” This may be psychologically traumatic as it asks patients to choose between treating their acne and affirming their gender identity, with some patients choosing to forgo acne treatment.64 In our experience, individualized discussion of ongoing advocacy efforts by dermatologists to promote gender-inclusive changes to the iPLEDGE system may help develop a therapeutic alliance, allay patient concerns regarding cultural competency of the provider, and facilitate access to isotretinoin treatment.60,63,64

Estrogen / Antiandrogen Therapy

For transfemale or nonbinary patients undergoing estrogen and/or antiandrogen therapy, acne may be improved by several potential mechanisms, including direct opposition of androgens, negative feedback loop on gonadotrophin release, and/or gene modulation responsible for sebum and lipid production.65,66 Many transfeminine patients receiving estradiol and anti-androgens, such as spironolactone, often notice improvement in their acne.43 For transfeminine patients with acne recalcitrant to hormone therapy, endocrine evaluation to titrate feminizing hormone doses and to rule out underlying hyperandrogenic states should be considered.

Other Considerations

Chest binding involves the use of ace bandages or elastic bands to tightly bind breasts in order to achieve a more masculine contour.67,68 While one small study suggested that chest binding does not negatively affect acne severity in transgender men receiving testosterone,52 there have been reports of acne and folliculitis, along with itching, pain, and scarring, associated with prolonged chest binding practices.68 Cosmetics and make up is another mean for patients to explore or affirm their gender identity or sexual identity. Discussion of cosmetic use and anticipatory guidance regarding non-comedogenic products should be provided.69

Conclusion

Most adolescents experience acne vulgaris during puberty regardless of their sexual orientation or gender identity. For SGM adolescents, however, comprehensive acne care requires dermatologists to actively engage in culturally competent discussions of sexual health, contraception, and/or gender-affirming therapy. Dermatologists should recognize that acne and SGM status are both independent risk factors for mental health comorbidity, including depression and suicide. Screening and referral to mental health providers should accompany, rather than hinder, moderate to severe acne care for SGM adolescents who suffer from both acne and mental health disorders. Gender-affirming hormone therapy is associated with changes in acne presentation and severity. Dermatologists should help transgender or gender nonbinary adolescents navigate sexual health, contraceptive, logistical considerations in accessing isotretinoin for the treatment of severe acne.

KEY POINTS.

  1. Comprehensive care for moderate-to-severe acne in sexual and gender minority adolescents should include culturally competent discussions of sexual health, contraception, and/or gender-affirming therapy.

  2. Dermatologists should consider psychosocial factors and mental health issues such as depression and suicidal ideation in sexual and gender minority teenagers with acne.

  3. Gender-affirming hormone therapies in transgender and gender nonbinary teenagers impacts acne presentation, treatment, and prognosis.

SYNOPSIS.

While most teenagers experience acne, for sexual and gender minority teenagers, acne could be more challenging and require specific psychosocial considerations. Acne may be more strongly associated with mental health issues in sexual and gender minority adolescents. Acne development during puberty may trigger gender dysphoria in transgender patients. Transgender and gender nonbinary patients receiving testosterone therapy may experience new or worsening acne. Comprehensive care for moderate-to-severe acne in sexual and gender minority adolescents should include culturally competent discussions about sexual behaviors, contraception, and/or gender-affirmation treatment plans.

Acknowledgments

DISCLOSURE STATEMENT

Dr. Yeung was supported in part by the National Center for Advancing Translational Sciences (NCATS) of the National Institutes of Health under award number UL1TR002378 and KL2TR002381. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Dr. Yeung has received honorarium from Syneos (InVentiv) Health. All other authors disclosed no financial conflicts of interest.

Footnotes

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