accutane for testosterone acne

birch rosen

Every morning and night, I peel back a tab with an image of a pregnant woman and a prohibition sign, push a pill through a thin layer of foil, and take my medication. These are only some of the 28 warnings not to get pregnant printed on the package of a 5-day supply. Once a month, I see my doctor to renew my vow of abstinence and submit to a laboratory urine pregnancy test to confirm that I am not, despite my abstinence, pregnant. If I do get pregnant, my pregnancy will be recorded in a government registry. No, this is not dystopian fiction — this is what I go through to treat my testosterone-induced acne as a “female patient who can get pregnant.”

The medication I take, best known by the trademark Accutane (generic name isotretinoin), is known for its potentially severe side effects and is considered something of a last-resort acne treatment. I took my first course of it as a teenager, when a dozen other topical, hormonal, and antibiotic medications had failed to reduce my cystic acne. I’m taking it again now because the testosterone that brings my body closer to my nonbinary sense of self also causes me to develop painful, long-lasting acne nodules on my face, chest, and back.

Isotretinoin’s potential side effects include dry eyes and skin, liver disease, and changes in mental health. But by far the most time, attention, and regulation are devoted to its potential effects on pregnancy.

Isotretinoin—as the 19-page guide for female patients who can get pregnant, the 36-page birth control workbook, and the diagrams of disabled babies on every package will tell you—can cause miscarriages, premature births, and congenital physical and intellectual/developmental disabilities. For these reasons, the Food and Drug Administration requires a Risk Evaluation and Mitigation Strategy for isotretinoin, which is called iPledge. Certainly, patients should be informed of the reproductive risks associated with isotretinoin and given the knowledge and resources necessary to minimize those risks. But the iPledge program grossly oversteps into dictating patients’ choices about their bodies.

Taking testosterone as a trans person has been a powerful way of claiming ownership and control of my body and sexuality. Our culture and media have taught me that my value lies in my fertility and my attractiveness to men, and I’ve rejected those values in favor of comfort and pleasure in my own body. iPledge, meanwhile, makes it clear that my body belongs to the federal government and the hypothetical baby I would never willingly give birth to.

I knew before I started my current course of isotretinoin that it would be bad. Taking it as a teenager had taught me the ins and outs of the iPledge program: in addition to the monthly pregnancy testing, I would have to use two methods of birth control simultaneously from a month before starting isotretinoin to a month after finishing it. At least one of these methods must come from a list of approved primary methods that includes hormonal and surgical methods and IUDs but notably excludes condoms. 

That would be a problem. In an earlier draft of this essay, I belabored my reasons for rejecting each approved primary method, but they don’t really matter. What matters is: it’s my body and I decide what to do with it. Condoms are highly effective when used correctly, and if it came down to it, I would get an abortion.

Notably, iPledge relegates condoms to its list of acceptable secondary methods despite their high effectiveness. According to Planned Parenthood, condoms are 98 percent effective when used correctly. That makes them more effective than half of the approved primary birth control methods, according to the rates cited in iPledge’s “Guide to Isotretinoin for Female Patients Who Can Get Pregnant.” Curiously, iPledge does not include effectiveness figures for condoms in its documents. Rather than providing patients with the information they need in order to make the right decisions for themselves, iPledge seemingly withholds it in a manner calculated to manipulate their perceptions of the effectiveness of contraception and their reproductive choices.

In the face of these overreaching and somewhat arbitrary regulations, I have maintained autonomy over my body and sex life by lying to my dermatologist.

While condoms are deemed insufficient, “not having sex or sexual contact with any male 24 hours a day, 7 days a week” is embraced as such a reliable solution that iPledge does not require a second form of birth control for abstinent patients, despite noting that “one of the most common reasons that women get pregnant is that they do not avoid sexual activity when they plan to be abstinent.” So as far as iPledge is concerned, I am abstinent.

There are other glaring omissions in the iPledge resources: most notably, no acknowledgement of the existence of abortion or trans people. 

For all the talk of miscarriages and disabled babies whose existence must be prevented, it’s strange that the program never mentions that pregnancy is not only preventable, but also terminable. No discussion of birth control is complete without recognizing abortion as a possibility. Furthermore, the pamphlets repeatedly refer to “unborn babies”—a framing often used by anti-abortion activists. If I were to get pregnant, there would not be an unborn baby inside me; there would be a not-yet-aborted fetus.

The omission of trans people is a problem in itself and also exacerbates my other problems with isotretinoin packaging and the iPledge system. The erasure of my existence as a nonbinary person is a daily fact of life in our cissexist society, but there are situations in which that erasure is especially harmful. It’s well-known among trans people who take testosterone and the doctors who treat us that testosterone often causes acne. It’s a short mental leap to anticipate that many of us would take isotretinoin to treat that side effect. When discussing topics such as pregnancy, in which gender and reproductive anatomy are often conflated, it is especially important to use specific and sensitive wording. iPledge makes no such effort.

For me, the problem starts with “female patients who can get pregnant.” Per iPledge’s own criteria, this really means “patients who have a uterus and at least one ovary and have not been confirmed by a doctor to have gone through menopause.” That’s a bit of a mouthful, but it’s specific and doesn’t introduce any extraneous factors. More realistically, even “patients who can get pregnant,” without the unnecessary gendering, would be a huge improvement.

Some people would argue that “female” refers to sex, not gender, and is therefore appropriate to use. But as long as my categorization as “female” leads people to automatically assume I’m a woman, “female” is gendered. (Asher Bauer gives an excellent, more thorough breakdown of the social construction of sex in “Not Your Mom’s Trans 101.”) iPledge also conflates gender with anatomy in more obvious ways, referring to patients as women, with she/her pronouns, and as prospective mothers. The iPledge materials and their sloppy categorization of me no doubt contribute to the constant misgendering I also face from the staff at the dermatology clinic I’m required to visit monthly.

Misgendering is more than a nuisance. It’s a reminder that people and institutions I rely on for care misunderstand fundamental aspects of my identity and needs. It’s a microaggression (and usually an accident) each time it happens, but the constant incidents pile up, isolating me from the world and accumulating in my body as toxic stress. I want to avoid the dermatologist’s office, even though I’m required to show up once a month. When I begrudgingly come in, my body is braced for fight or flight the whole visit. I have to insistently advocate for correct gendered recognition while lying about my sex life in order to access treatment.

The iPledge system, while purporting to have my best interests at heart, subjects my sex life to government surveillance, misgenders me and my partner, omits relevant facts about preventing births, and incentivizes lying to my doctor. 

It’s difficult to suggest fixes to a system with so many flaws, and such serious ones at that. Some ideas are more obvious and simpler to implement: switching to gender-neutral, anatomy-focused language in materials about isotretinoin and training medical staff about how to use respectful language for transgender patients.

But neither of these get to the heart of the problem: iPledge is a system for patient surveillance, not empowerment. To truly support patients, the FDA would have to switch to an informed-consent model: giving patients the knowledge and tools necessary to make the choices that are right for their circumstances. In a country that’s constantly trying to decrease abortion access and deny young people information about contraception and queer and trans existence, that seems like a lot to ask.

But wasn’t the whole point of this medication to feel comfortable in my own skin?

about the artist

Birch Rosen (they/them) is an agender writer, poet, zinester, and performer who uses personal writing to create space for more nuanced trans and nonbinary narratives. Their zines include T&A (Transitioning & Attractiveness) and Trans Restroom Rants, and their writing has appeared in the Michigan Quarterly Review.