The Case of the Transgender Considerations for Cancer Screening
Editor’s note: This article was revised based on reader feedback. You are reading the revised version.
Sally, a nurse practitioner in a cancer survivorship clinic, is preparing to discuss screening and surveillance guidelines with Jonah, a 32-year-old survivor of Hodgkin lymphoma. Sally reviews Jonah’s patient history form and notes that Jonah uses he and him pronouns. His gender identity is male and sex assigned at birth was female. Jonah’s surgical history includes gender-affirming surgery on chest tissue (also known as top surgery), and his current medications include supplemental testosterone. Jonah also specifies that he is transmasculine—an umbrella term used to indicate that Jonah feels a connection with masculinity.
What Would You Do?
Transgender people identify with a gender different from the biologic sex they were assigned at birth. Transmasculine, transfeminine, transgender, and gender nonconforming individuals express varying degrees of masculinity and femininity (https://doi.org/10.1080/10463356.2019.1667673), and some may have chosen to undergo gender confirmation surgery. Oncology clinicians need to know which body parts a person has retained since birth to best address cancer screening guidelines. For instance, a person who identifies as transmasculine may still retain a uterus, cervix, and other organs that may be at risk for cancer.
Of the 27,715 respondents to the 2015 National Transgender Discrimination Survey, 8% of the transmasculine cohort indicated removal of their uterus and cervix. Yet only 27% (https://fenwayhealth.org/wp-content/uploads/TFIP-28_TransMenCervicalCancerScreeningBrief_web.pdf) of the transmasculine group reported having a Pap test in the past year. Because the majority of the transmasculine cohort retained their risk for uterine and cervical cancer, oncology nurses must educate transgender patients about their risk and advocate for cancer screening. However, in the year prior to the survey, 33% of respondents had negative healthcare experiences, 23% did not seek health care (https://transequality.org/sites/default/files/docs/usts/USTS-Full-Report-Dec17.pdf) for fear of discrimination, and 33% could not afford health care—which sheds light on the critical need for increased cultural competence among providers.
Sally tells Jonah that anyone with a cervix should consider having a Pap test. Jonah admits he never pursued cervical cancer screening for fear of discrimination and the anxiety of submitting to a vaginal exam. Sally validates his concern by telling him that the use of testosterone can cause vaginal atrophy, which under the wrong circumstances could make a Pap test painful. People using testosterone can also have false-positive screening (https://doi.org/10.1080/10463356.2019.1667673) findings. For these reasons, Sally engages in a more robust conversation with Jonah to the explore concerns and apprehensions he is feeling. One of her recommendations is to involve a gynecologic provider skilled in caring for transgender people in Jonah’s care. Cultural competence on Sally’s part can help her empathize with Jonah and prepare him for cervical cancer screening.