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Letter to the Editor: Amending iPLEDGE: Why “Abstaining from Abstinence” May Harm LGBTQ+ Patients

J Clin Aesthet Dermatol. 2021;14(2):12–13.

Dear Editor:

iPLEDGE, the risk evaluation and mitigation strategy program for isotretinoin, has been criticized for being unnecessarily complex, antiquated, and ineffective. It mandates that those with ovaries and a uterus who are premenopausal either take two forms of contraception or sign an abstinence pledge when starting isotretinoin. In a recent article published in the Journal of Clinical and Aesthetic Dermatology titled, “iPLEDGE Must Abstain from Abstinence”, Lowery et al1 argue for new guidelines titled iPLEDGE-R, which abolishes the abstinence option due to inefficacy, and instead requires all isotretinoin patients to use contraception. However, we believe that mandating contraceptives could harm the physical and mental health of people who do not interface with sperm (PDNIS), including, but not limited to, cis-women who have sex with cis-women and transmen who have sex with cis-women or transmen. Rather than abolishing the abstinence option, we are calling for iPLEDGE to encourage physicians to have more open, individualized, and ongoing conversations about their patients’ sexual history and preferences and to explicitly incorporate more LGBTQ+-friendly language to educate dermatologists about this growing population.

Mandating contraceptives through iPLEDGE-R for PDNIS has physical, mental, and ethical implications. Contraceptives are not benign medications; there is extensive literature on their potential side effects, ranging from increased menstrual bleeding, pain, mood changes, and weight gain to life-threatening thromboembolism, cardiovascular disease, or neoplasia.2 Not only is this especially burdensome for PDNIS but some patients could also perceive this as overmedication, which has been linked to decreased adherence, reduced health-related quality of life, and adverse reactions.3

From a mental health perspective, pushing contraceptives, a heteronormative practice, onto PDNIS teens can be harmful for their early identity formation, trust in the health care system, and overall mental health.4 It is widely documented that societal rejection, stigma from health care providers, and victimization are tied to higher rates of depression, substance use, and suicidality in LGBTQ+ youth.5 

Some might retort that PDNIS should select another treatment for nodular acne if they cannot comply with iPLEDGE’s isotretinoin guidelines. Yet, isotretinoin is widely marketed as the single best treatment for nodular acne by both iPLEDGE packets and dermatologists. Denying PDNIS individuals the right to this medication because of their sexuality is unethical.

It is clear that the iPLEDGE guidelines must be updated to properly serve the modern patient population. Strikingly, iPLEDGE packets have little to no language to guide LGBTQ+ patients or providers treating LGBTQ+ patients, although there are 15 million self-identified LGBTQ+ individuals alone in the United States. iPLEDGE should provide resources on their website and packets to encourage dermatologists to use LGBTQ-friendly language and take a personalized medicine approach. These simple changes will empower dermatologists to create safe spaces for all patients, regardless of the sexuality or gender identity stated at consultation, to share not only a detailed present sexual history but also to have an open dialogue at each monthly visit about whether those identities or behaviors have changed and whether contraception is now needed. This is one of many ways iPLEDGE must be amended to ensure that it is the most inclusive it can be.

With regard,

Kanika Kamal, BA;
Alexandra Charrow, MD, MBE;
and Avery LaChance, MD, MPH

Affiliations. Ms. Kamal is with Harvard Medical School in Boston, Massachusetts. Drs. Charrow and LaChance are with the Department of Dermatology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts.

Funding. No funding was provided for this article.

Disclosures. The authors declare no conflicts of interest related to the content of this article. 

Correspondence. Avery LaChance, MD, MPH; Email: alachance@bwh.harvard.edu.

References

  1. Lowery K, Rosen T, Malek J. iPLEDGE must abstain from abstinence. J Clin Aesthet Dermatol. 2020;13(6):54–56.
  2. National Research Council (US) Committee on Population. Contraception and Reproduction: Health Consequences for Women and Children in the Developing World. Washington (DC): National Academies Press (US); 1989.
  3. Fincke BG, Miller DR, Spiro A. The interaction of patient perception of overmedication with drug compliance and side effects. J Gen Intern Med. 1998;13(3):182–185.
  4. Brenick A, Romano K, Kegler C, Eaton LA. Understanding the influence of stigma and medical mistrust on engagement in routine healthcare among black women who have sex with women. LGBT Health. 2017;4(1):4–10.
  5. Almeida J, Johnson RM, Corliss HL, et al. Emotional distress among LGBT youth: the influence of perceived discrimination based on sexual orientation. J Youth Adolesc. 2009;38(7):1001–1014
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