Cancer risk in the transgender community

Abstract

On July 8, WHO released a new policy summarising recommendations for HIV control and care in transgender populations. Usefully, the brief emphasised specific considerations for transgender men (trans men) regarding cervical cancer screening. On July 27, the UK Government similarly initiated a parliamentary inquiry into transgender equality. The inquiry will examine National Health Service provisions for transgender people, along with ways of combating discrimination and inequality. Amid high-profile transgender health topics, cancer is often overlooked. Indeed, there is scant information on cancer outcomes for transgender people because of an absence of large-scale prospective studies investigating cancer incidence and mortality in lesbian, gay, bisexual, and transgender people. Furthermore, population cancer statistics do not include details of sexual orientation or status, so relevant information is often missed.Case reports and anecdotal evidence suggest that transgender people have a disproportionate cancer burden, but without high-level evidence, health-care providers are stifled in their ability to provide adequate guidance. What is clear is that a complex collection of issues affect the ability of transgender people to access timely and effective cancer care. One such issue is the possibility of discrimination that discourages transgender people from seeking medical help. According to a 2011 report by the US National Center for Transgender Equality and the National Gay and Lesbian Task Force, transgender people frequently face discrimination by health-care providers. This is further underlined by a World Report published in The Lancet on August 21, which documents how a lack of provider knowledge about transgender health in the USA might result in intrusive questioning and harassment. Discrimination plays an important part in the logistics of cancer screening as well. Screening programmes for gynaecological and genitourinary cancers might fail to identify eligible transgender participants and must consider how to provide access without publicly revealing a participant's sex at birth. According to the WHO report, trans men are often not included in screening programmes for cervical cancer despite retaining some or all of their natal genitalia. Moreover, fear of discrimination could prevent transgender people from taking advantage of these services.Transgender people are particularly vulnerable when it comes to health care, not only because of discrimination, but also because of distinct health requirements. Transgender men and women remain susceptible to cancers of reproductive organs that are no longer in alignment with their gender. For example, trans women might not recognise the persisting risk of prostate cancer. Those who have undergone sex reassignment surgery might be unaware of the continuing possibility of reproductive cancers due to residual tissue that remains after surgery. This can be complicated by the transgender people opting out of cancer screening and examinations because of emotional or physical distress associated with the discordance between their gender and their natal genitalia.Disengagement from gender-oriented health care, for any reason, results in missed opportunities for cancer screening and diagnosis, and likely contributes to care disparities in this population. Crucially, this is compounded by the increased risk of cancer in the transgender population. The use of oestrogen, progestin, and testosterone, to induce or sustain sex transitions, are often used in excessive doses and continued without medical guidance—the effect of this on cancer development is unclear. Additionally, actions considered preventative for certain gynaecological cancers in non-trans women, such as taking the birth control pill, might not be considered by trans men. Finally, as reported for lesbians, gay men, and bisexual people, transgender people are also more likely to smoke and drink alcohol, and have a greater chance of contracting HIV and human papillomavirus than the overall population, all of which contribute to an increased cancer risk.Cancer care for transgender people is a growing concern and health-care services that are both respectful of this population's differences, and also relevant to and inclusive of them are needed. Moreover, research into how cancer affects the transgender community, as well as how to prevent, screen, and treat cancer in this population, will improve cancer control. Better integration of the needs of people with non-traditional genders and sexualities in health care will help combat enduring health inequalities. On July 8, WHO released a new policy summarising recommendations for HIV control and care in transgender populations. Usefully, the brief emphasised specific considerations for transgender men (trans men) regarding cervical cancer screening. On July 27, the UK Government similarly initiated a parliamentary inquiry into transgender equality. The inquiry will examine National Health Service provisions for transgender people, along with ways of combating discrimination and inequality. Amid high-profile transgender health topics, cancer is often overlooked. Indeed, there is scant information on cancer outcomes for transgender people because of an absence of large-scale prospective studies investigating cancer incidence and mortality in lesbian, gay, bisexual, and transgender people. Furthermore, population cancer statistics do not include details of sexual orientation or status, so relevant information is often missed. Case reports and anecdotal evidence suggest that transgender people have a disproportionate cancer burden, but without high-level evidence, health-care providers are stifled in their ability to provide adequate guidance. What is clear is that a complex collection of issues affect the ability of transgender people to access timely and effective cancer care. One such issue is the possibility of discrimination that discourages transgender people from seeking medical help. According to a 2011 report by the US National Center for Transgender Equality and the National Gay and Lesbian Task Force, transgender people frequently face discrimination by health-care providers. This is further underlined by a World Report published in The Lancet on August 21, which documents how a lack of provider knowledge about transgender health in the USA might result in intrusive questioning and harassment. Discrimination plays an important part in the logistics of cancer screening as well. Screening programmes for gynaecological and genitourinary cancers might fail to identify eligible transgender participants and must consider how to provide access without publicly revealing a participant's sex at birth. According to the WHO report, trans men are often not included in screening programmes for cervical cancer despite retaining some or all of their natal genitalia. Moreover, fear of discrimination could prevent transgender people from taking advantage of these services. Transgender people are particularly vulnerable when it comes to health care, not only because of discrimination, but also because of distinct health requirements. Transgender men and women remain susceptible to cancers of reproductive organs that are no longer in alignment with their gender. For example, trans women might not recognise the persisting risk of prostate cancer. Those who have undergone sex reassignment surgery might be unaware of the continuing possibility of reproductive cancers due to residual tissue that remains after surgery. This can be complicated by the transgender people opting out of cancer screening and examinations because of emotional or physical distress associated with the discordance between their gender and their natal genitalia. Disengagement from gender-oriented health care, for any reason, results in missed opportunities for cancer screening and diagnosis, and likely contributes to care disparities in this population. Crucially, this is compounded by the increased risk of cancer in the transgender population. The use of oestrogen, progestin, and testosterone, to induce or sustain sex transitions, are often used in excessive doses and continued without medical guidance—the effect of this on cancer development is unclear. Additionally, actions considered preventative for certain gynaecological cancers in non-trans women, such as taking the birth control pill, might not be considered by trans men. Finally, as reported for lesbians, gay men, and bisexual people, transgender people are also more likely to smoke and drink alcohol, and have a greater chance of contracting HIV and human papillomavirus than the overall population, all of which contribute to an increased cancer risk. Cancer care for transgender people is a growing concern and health-care services that are both respectful of this population's differences, and also relevant to and inclusive of them are needed. Moreover, research into how cancer affects the transgender community, as well as how to prevent, screen, and treat cancer in this population, will improve cancer control. Better integration of the needs of people with non-traditional genders and sexualities in health care will help combat enduring health inequalities. Cancer in the transgender communityThe Lancet Oncology editorial “Cancer risk in the transgender community”1 provides a timely and important insight into a patient population that has long been neglected. Prostate cancer in transgender women deserves special emphasis. Although only four cases of prostate cancer have been reported in this group, the reported incidence is very likely to be a gross underestimate for several reasons.2–5 Full-Text PDF