“That is a very heteronormative lens.”

These words were uttered to me by a 23-year-old female patient as I explained i-PLEDGE and the steps she must complete to take oral isotretinoin.

The visit started as fairly routine. A young female presented with a complaint of acne. I quickly appraised the patient on entering. She was petite, with a blonde pixie cut. She wore clothes that were punk. When she pulled her face mask down, her acne was mild.

She related the reason for her appointment was to start isotretinoin. Years of acne had taken a psychological toll. Although her symptoms were not severe, they did meet the criteria for isotretinoin.

I launched into my spiel about isotretinoin, how it works, and the side effects she would experience. I explained i-PLEDGE and that she would be required to be on two forms of birth control. I told her the FDA monitors the prescription and use of isotretinoin due to the risk of birth defects and spontaneous abortion.

I informed her that she would have to get labs each month, including a pregnancy test and that she couldn’t start the medication until she had two negative pregnancy tests 28 days apart. Part of this speech asked which two forms of birth control she planned on using while rattling off the list of approved methods, including male latex condoms.

When she asked if there were other options, I dismissively stated, “Well, you can select abstinence, but that is not a preferred method. So which methods would you like to use?”

She then looked me squarely in the eye and declared, “I’m gay.” I hesitated, unsure how to respond. I had never been confronted with this situation in my years of prescribing isotretinoin. I was familiar with the iPLEDGE Prescriber Guide and had been trained to avoid abstinence as an option. But that is when treating cisgender straight women — the only women I had prescribed isotretinoin to.

The Prescriber Guide mentions sexual contact (penis-vaginal) when outlining concerns for abstinence with isotretinoin. It mentions nothing about women having sex with women. My perspective as a cisgender straight woman was so heteronormative, that in the moment I was confounded about how to respond to the patient in front of me.

When I reiterated that she would need to select two forms of birth control or pledge to abstinence, she remarked that this was very heteronormative. I agreed. The way that iPLEDGE is set up is heteronormative. The way that I approached the patient was heteronormative.

The entire encounter had spiraled and was dissatisfying all around.

I am practiced in having conversations about structural racism in health care. But this is structural too. Our system is designed to treat cisgender, straight people. How can iPLEDGE not acknowledge that a person’s sexuality should be taken into account? This includes cis women who have sex with cis women but also trans men who have sex with cis women or trans men — people not exposed to sperm.

In December 2021, the FDA updated the iPLEDGE risk categories to those who can get pregnant and those who cannot. This is an important step in gender-affirming care but still categorized my patient as one who could get pregnant. In her case, the best option was to sign the abstinence pledge, attesting that she would abstain from penile-vaginal intercourse. This pledge did not absolve her from monthly pregnancy tests. There is no workaround in iPLEDGE for those who have a uterus and functional ovaries.

The enormity of the pregnancy tests did not fully resonate with me until I recounted this story to a colleague who identifies as LGBTQIA+. They shared a personal story about how damaging this is to someone who only has sex with cis women.

In my colleague’s case, they presented to the emergency department with near-syncope and abdominal pain. They were asked about their last menstrual period and if they could be pregnant. They insisted they could not. No one asked about sexual history. When the providers pressed for a urine pregnancy test, my colleague snapped. They weren’t being listened to; pregnancy was not an option and was not the problem. They finally had to yell out, “I have never had sex with a man!”

 A recent Gallup survey found that 7.1 percent of the U.S population identifies as LGBTQIA+. Providers encounter these patients and must be prepared to care for them in an inclusive way. Every health care provider should be responsible for disrupting the structures that dictate care for LGBTQIA+ patients.

The visit with my patient helped to change my perspective. I should not have made assumptions about her based on my implicit bias. I highly recommend the Harvard Implicit Bias tests as an exercise in introspection. We also need to share and reflect on our experiences — especially when we were clearly incompetent.

There are a number of systems in place that reinforce structural heteronormative care. We need to identify these structures and work to make them more inclusive. The confines of iPLEDGE are exemplary of the problem — the health care system is structurally heteronormative.

“The point is that by default, the dermatology office is a straight space. The world is full of straight spaces, doctors’ offices, gas stations, and H&R Blocks. It’s a lot. Being gay in a straight world can be exhausting.” These words are not my patient’s or my colleague’s but were expressed by Jayden, a character on Netflix’s Pretty Smart. Although these words were uttered in a fictional show, they ring true for the realities of patients who are LGBTQIA+. As providers, our priority should be to make these spaces inclusive by default.

Naila Russell is a nurse practitioner. She can be reached on Twitter @nailarussell.

Image credit: Shutterstock.com