Sexual orientation is the physical or emotional attraction of one person to another. Heterosexual persons are attracted to people of the opposite sex, homosexual persons (gays and lesbians) are attracted to people of the same sex, and bisexuals are attracted to people of both sexes.1,2
It is important to differentiate between sexual orientation and gender identity. Gender identity is a term that describes the perception of each person regarding their gender; people may identify as male, female, both, or neither (Table 1). We talk about cisgender people when the sex assigned at birth corresponds to the gender identity. The terms transgender, transsexual, “trans” or nonbinary gender are used for people whose gender identity does not correspond to the sex assigned to them at birth.1
Glossary of Terms.
| LGBTQI+ |
| Acronym for Lesbian, Gay, Trans, Bisexual, Queer, Intersexual, and other identities. |
| Cisgender person (non-transgender) |
| A person whose birth sex corresponds to their gender identity. |
| Transgender person |
| A person whose birth sex does not correspond to their gender identity. |
| Queer |
| This term may have 2 meanings: queer, as a way of encompassing the entire LGBTQI+ community, or gender queer/nonbinary gender, transgender people who do not identify with either male or female gender. |
| Intersexual |
| People with a reproductive anatomy that does not meet the classical definitions of man or woman. |
| Gender expression |
| The way in which a person expresses their gender identity. |
| Hormone/surgical gender affirmation/reassignment/confirmation treatment |
| Medical or surgical process that a transgender person undergoes to adapt their anatomy to their gender identity. |
| • Top surgery: F-M (mastectomy), M-F (breast augmentation surgery) |
| • Bottom surgery: F-M (metoidioplasty, phalloplasty, hysterectomy, and vaginectomy), M-F (vaginoplasty with or without penectomy, orchiectomy) |
| Not all transgender people undergo medical and/or surgical gender-affirmation treatment. |
| Gender dysphoria |
| A mental health term that refers to the anxiety felt by a transgender person due to the incompatibility between their body and their gender identity. |
| Not all transgender people experience dysphoria. |
Several articles have been published recently on the dermatologic care of LGBT people.1–3 Moreover, since 2017, the Spanish Academy of Dermatology and Venereology has been collaborating on a consensus report together with the AIDS Study Group of the Spanish Society of Infectious Diseases and Clinical Microbiology, which contains the recommendations for treating sexually transmitted infections in men who have sex with men, women who have sex with women, and transgender people.4
Following is a summary of the skin diseases and infections for which these people have increased risk and the preventive actions (Table 2) for each group, depending on their sexual orientation or gender identity.
Screening and Preventive Measures.
| Population | Screening | Vaccines and prevention |
|---|---|---|
| MSM | - HIV: annual- CT, NG (pharyngeal, rectal, and urine): annuala- Syphilis: annual- HAV (IgG): 1st visit- HBV (anti-HBs, anti-HBc, and HBsAg) and HCV: annualDepending on individual risk, assess need for screening every 3–6 months | - HAV (if anti-HAV IgG+IgM negative)- HBV (if anti-HBs negative)- HPV: if <26 years MSM and HIV. Evaluate the potential benefits of HPV vaccine in MSM (universal vaccination in children?)- Evaluate meningitis vaccination if not previously vaccinated- PrEP if HIV negative and at least 2 of the following criteria are met:- More than 10 different sexual partners in the past year- Practiced anal sex without protection in the past year- Used drugs during unprotected sexual relations in the past year- Administration of PEP on several occasions in the past year- At least 1 bacterial STI in the past year- PEP if HIV negative and exposure with elevated risk of transmission (anal sex or sharing syringes with an HIV+ person with a detectable or unknown viral load)• Rectal examination if perianal condylomata present- Insist on the use of condoms |
| WSW | Periodicity based on individual risk assessment:- HIV- CT, NG (endocervical or vaginal/urine if contraindicated) and trichomonas- Syphilis- HAV (IgG): 1st visit- HBV (anti-HBs, anti-HBc, and HBsAg) and HCV- Screening for cervical cancer regardless of history of STIs (including condylomata) | Preventive measures are the same as those for women who have sex with men- HBV (if anti-HBs negative) |
| Trans women (M-F) | Periodicity based on individual risk assessment:- HIV- CT, NG (individualized sample collection)- Syphilis- HAV (IgG): 1st visit- HBV (anti-HBs, anti-HBc, and HBsAg) and HCV | If sex with men (follow same recommendations as for MSM)• PrEP if criteria met (seer Vaccines and prevention, MSM)• Insist on the use of condoms |
| Trans men (F-M) | Periodicity based on individual risk assessment:- HIV- CT, NG, trichomonas (individualized sample collection)- Syphilis- HAV (IgG): 1st visit- HBV (anti-HBs, anti-HBc, and HBsAg) and HCV- Breast and genital examination, cervical cancer screening (individualize depending on gender confirmation surgery) | If sex with men (follow same recommendations as for MSM)• PrEP if criteria met (seer Vaccines and prevention, MSM)- Insist on the use of condoms |
Individual assessment of risk of STIs: clinical records and sexual behavior (history of STIs, number of partners, use of condoms, use of drugs during sexual relations, sex workers, etc.).
Abbreviations: CT indicates Chlamydia trachomatis; MSM, men who have sex with men; STI, sexually transmitted infection; WSW, women who have sex with women; NG, Neisseria gonorrhoeae; PEP, post-exposure prophylaxis; PrEP, pre-exposure prophylaxis; HAV, hepatitis A virus; HBV, hepatitis B virus; HCV, hepatitis C virus; HIV, human immunodeficiency virus; HPV, human papilloma virus.
Men who have sex with men: in Spain, in 2017, more than 50% of new cases of infection with the human immunodeficiency virus were diagnosed in men who have sex with men. Increased risk of syphilis, gonorrhea, chlamydia, hepatitis, genital herpes, lesions due to the human papilloma virus (including anal cancer, with a higher risk in men who have sex with men and human immunodeficiency virus), meningococcal disease, and infection with methicillin-resistant Staphylococcus aureus has also been reported. Furthermore, some studies talk about an increased risk of nonmelanoma skin cancer and melanoma linked to the use of tanning booths.1,4
Women who have sex with women: although there is a lesser perception of the risk of contracting some sexually transmitted infections owing to the type of sexual practices, an increase in infections due to chlamydia, herpes, and bacterial vaginosis, as well as oral lesions due to the human papilloma virus, has been reported.1
Transgender: persons undergoing hormone and/or surgical gender-confirmation treatment may present specific adverse effects that dermatologists should be aware of:
Transgender men (transition from woman to man): testosterone treatment may trigger acne or androgenetic alopecia. It is important to continue to screen for cervical cancer and to perform breast and genital examinations if the patient has not undergone gender confirmation surgery.1,3,5
Transgender women (transition from man to woman): treatment with exogenous estrogens increases the risk of thromboembolism compared to cisgender people. Squamous cell carcinoma and scleroatrophic lichen in neovagina and vulva, and skin diseases associated with cosmetic processes (fillers) used for feminization of the face and body.1–3
Dermatologists play a significant role in the health of the LGBT community. Awareness of the increased risk of sexually transmitted infections and their prevention, skin diseases inherent to the community, and inclusive language are some of the crucial aspects needed to treat these patients.
Conflicts of interestThe authors declare that they have no conflicts of interest.
