A look at the barriers for transgender people getting cancer screenings

CATHY WURZER: I'm Cathy Wurzer. Thanks for being with us. No one likes mammograms or prostate exams, right? But they can help spot cancer when it's treatable. But for transgender patients, these cancer screenings are more than just uncomfortable.

They force trans people to acknowledge body parts they no longer identify with, not to mention the vulnerability and distrust trans patients have in navigating health care settings. Dr. Jamie Feldman is on the faculty at the Institute for Sexual and Gender Health at the University of Minnesota. Her published research primarily explores transgender health and medicine.

She also co-authored versions 7 and 8 of the World Professional Association for Transgender Health's standards of care. Dr. Feldman is on the line right now. Nice to have you here. Thank you.

JAMIE FELDMAN: Thank you very much. It's a pleasure to be here.

CATHY WURZER: Let's start by talking about the cancer risk among trans people. Is there any evidence to determine the long-term effects of gender-affirming hormone therapy on an individual's cancer risk?

JAMIE FELDMAN: There is some evidence. And it depends on what kind of cancer we're talking about. So, certainly, there are cancers that are not related to hormone therapy, such as colon cancer or lung cancer. Those aren't generally affected by one's sex hormones. But, certainly, there are studies, long-term studies, that look at hormone effects on cancers that may be related to hormone levels in the body over time, such as breast cancer, prostate cancer, uterine cancer, or ovarian cancer.

And the difficulty with some of these studies is that trans and gender diverse people may start these hormone therapies at different ages in their life. And so we have to look at them-- most of the data we have is looking at trans people overall and not taking a cohort of people who have all started hormones at the same time. Generally speaking, there is no evidence for hormone therapy increasing the risk of cervical cancer in those people with the cervix or uterine cancer, ovarian cancer.

There is some evidence that breast cancer among trans women may be increased compared to people who have not done gender-affirming hormone therapy with estrogen, but less than cisgender women, who've had a lifetime of estrogen exposure from puberty on up. Prostate cancer among those with prostates who have taken estrogen is likely reduced but not to zero.

And there is no evidence that testosterone therapy increases the risk of ovarian, uterine, cervical, or uterine cancer. But it doesn't decrease those risk either as long as you have those body parts.

CATHY WURZER: Thank you for that information. I was curious about that. And doing research for this conversation of ours, I noticed there are currently very few transgender-specific cancer screening recommendations. So what's a trans person to do?

JAMIE FELDMAN: So because of the nuances of when people start hormone therapy, and because of the lack of long-term research specific to trans people, and in light of all of the gendered guidelines that are really focused on cisgender people and a very binary view of both sex at birth and gender, we really have to parse things out, both for physicians, who have been trained in a very sex-binary and gender-binary world, not to mention electronic medical records and all sorts of things that reinforce that binary.

We have to really develop guidelines and help people think about how to apply those guidelines to a trans setting. So, for example, we want to really look at people-- people have a gender-- and we want to look at people's bodies and then the hormone exposure that that body has had. So, for example, take a trans woman who began hormone therapy at age 45.

And the current guidelines say that all women, not distinguishing between trans women and cisgendered women, should start mammography at age 50, sometimes depending on the guideline 45 to 50. Remember, guidelines aren't even that clear for cisgendered women. And if we think about it, if you just started taking hormones and growing breast tissue at age 45, there isn't a whole lot of breast tissue, and you haven't had a whole lot of estrogen exposure in just five years.

So the risks of breast cancer at that point are pretty low for the average person. So you likely get over-screened. So we really think about that, we have to kind of think about that in terms of what the physiology and breast cancer risk is.

And that's why we do individualized patient-centered counseling about, well, let's think through what that means for you. And that really is what we call for, for example, in prostate cancer screening right now for cisgendered men. So it's just taking that a little bit further when we apply current guidelines and we educate our patients in the primary care setting or in a gender clinic is really just taking those guidelines and saying, OK, let's talk about as an individual. What's your individual risk?

CATHY WURZER: And let me ask you about the individual at this point, because cancer screenings can be difficult, as I mentioned in my introduction, for folks who are transgender. You're talking about the vagina, cervix, prostate-- they're treated as gendered in health care, right? So that can be really difficult for trans and gender-diverse people. How do you help them have to put up with these cancer screenings when it can be really difficult?

JAMIE FELDMAN: Oh, absolutely. And so the first place is to really make sure that your clinic and you as a physician or provider really have a gender-affirming and gender-welcoming environment in your clinic so that patients, all patients, want to come to you and feel safe and affirmed in your clinic and that you are a safe and gender-affirming provider.

So making sure that your front desk staff, your clinic setting, and you are respectful-- that's using an appropriate name for your patient, one they want to use and recognize, that you're using a person's correct pronouns, and that you're using terms for body parts that are appropriate for the patient, but still get that message across that you're communicating about the same body parts. So if you're talking about genitals or gonads, reproductive organs, that you're not necessarily talking about a vagina unless you really have to distinguish that from other genital parts so the patient doesn't feel like you're saying, oh, well, that's a woman thing, and I'm not a woman.

That's the first kind of welcoming step. Then is to really distinguish that you have a cervix, and that cervix needs to be taken care of, whatever your gender is, whether that's non-binary, male, or female. So let's figure out how to take care of your cervix. And let's talk about screenings and how to make those screenings comfortable for you. And here are those options.

The next piece is, then, if you have to refer to someone else for those screenings, like mammography. Well, I don't do mammography in my office. I have to refer to an x-ray, a mammography technician. And so I have to make sure that that technician in that environment is inclusive and gender-affirming and that that person uses names, and pronouns, and makes sure that my patient feels comfortable. And so it's a whole systemic effort. But if we do that correctly, people will engage in screening.

CATHY WURZER: Say, I have about, I'm sorry, 30 seconds left, 45 seconds left-- and there's a lot to talk to talk about here, obviously. Are there good resources available for trans patients who want to find a gender-affirming doctor?

JAMIE FELDMAN: Oh, absolutely. So there are local resources here in Minnesota. The Rainbow Health Organization, M Health Fairview's Comprehensive Gender Care Center, the national center here at the Institute for Sexual and Gender Health, it's a subunit. M Health Fairview's primary care group, particularly our residents, our family medicine residents, are trained to provide gender-affirming general health care, and as well as other organizations, including the World Professional Association for Transgender Health has a directory.

CATHY WURZER: Good.

JAMIE FELDMAN: So those are all sorts of good resources.

CATHY WURZER: All right. Doctor, thank you for the conversation.

JAMIE FELDMAN: OK. You're entirely welcome.

CATHY WURZER: Dr. Jamie Feldman is on the faculty at the Institute for Sexual and Gender Health at the U of M.