Response to Reader Comment on "Considerations in Treating Severe Acne With Isotretinoin in Transgender Men".

We thank Dr Haber for his interest in and response to our article[1] on the topic of isotretinoin use in transgender men. Furthermore, we thank him for bringing additional awareness of this underserved population to our scientific and professional community. The objective of our letter was to encourage open communication between dermatologists and transgender patients in order for the treating dermatologist to gain a better understanding of the benefits and risks of isotretinoin therapy in this population. Dr Haber points out that pregnancies have occurred in transgender males with native female reproductive organs and cites a web-based study of trans men with retained female reproductive organs who became pregnant. The study showed that 20% of these transgender men were taking testosterone at the time they became pregnant.[2] At present, there are no published rates of pregnancies amongst the general transgender male population.[3] However, numerous cases have been reported. For example, between 2009 and 2019, Australia’s Medicare recorded 228 pregnancies in transgender men.[4] While the “risk” of pregnancy remains difficult to quantify, it is without question real. If open discussion of a transgender male patient’s anatomy and sexual practices uncovers that risk exists, it must be managed with the introduction of an acceptable means of pregnancy prevention and pregnancy tests performed at baseline and routinely monitored.

We read with interest the 2016 article[5] referenced by Dr Haber, which examines how to classify a trans man in the iPLEDGE system used in the United States. iPLEDGE demands that patients be identified according to sex assigned at birth[6] and does not include a category for trans men with retained native female organs. This leaves the physician with the ethical dilemma of choosing between the obligation to do no harm (nonmaleficence) and the right of the patient to self-determination and self-identification (patient autonomy). The physician must either ignore iPLEDGE’s mandate to classify the patient based on sex assigned at birth (risking suspension or deactivation with iPLEDGE) or classify the patient as a female of reproductive potential. The latter may be unacceptable to some trans males and prevent them from accessing isotretinoin or add to negative health care experiences. The authors of the article conclude by recommending modifications to the present iPLEDGE system.

In Canada, we are not bound by a system like iPLEDGE. However, with this freedom still comes the responsibility of having in-depth conversations with each patient and conscientiously managing their risk factors for teratogenicity and other potential complications of isotretinoin therapy. We remain committed to bringing the potentially high benefits of isotretinoin treatment to the trans community by ensuring appropriate discussion, counseling, and patient-specific monitoring in all patients.