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Transgender patients: considerations for routine gynecologic care and cancer screening
Trinidad Labanca, Ivan Mañero, Marcelo Pannunzio
ABSTRACT
In the last several years, demand for transgender care from gynecologists has increased significantly. Transgender people comprise a diverse group who do not identify with the sex they were assigned at birth. Worldwide, it is estimated that 25million people identify as transgender. Some undergo hormonal and/or surgical treatment aiming to feminize or masculinize their bodies. Cross-sex hormone treatment for transgender women—individuals assigned as male at birth who identify themselves as women—includes exogenous estrogen and/or progestin administration in combination with anti-androgens, whereas testosterone is used for transgender men—individuals whose natal sex is women but identify themselves as men. Although it is usually rare, hormone-sensitive malignancies may arise, and long-term effects remain unknown. In addition, reconstructive surgeries may include breast augmentation and vaginoplasty (creation of a vagina) for transgender women, and chest masculinization surgery (bilateral mastectomy), and metoidioplasty (lengthening of the clitoris to create a microphallus) or phalloplasty (creation of a phallus) for transgender men. Evidence relating to breast and reproductive tract cancers in the trans population is limited and insufficient to estimate cancer prevalence, and recommendations for screening and preventive care depend on the patients’ hormonal and surgical status. Even less information exists regarding the sub-set of individuals with a genetic predisposition for these malignancies. In this review, we aimed to summarize current recommendations for gynecologists and gynecologic oncologists regarding cancer screening and personalized cancer-risk assessment in transgender people.
INTRODUCTION
The American College of Obstetrics and Gynecologists (ACOG) and the Royal College of Obstetricians and Gynecologists (RCOG) recommend that gynecologists deal with sexual health in routine clinical practice and encourage not making assumptions or judgments on patients’ sexual behavior, including relationships and sexual practices, aiming to promote sexual health as a right for every person.1 Gender diversity is an important part of sexual health, and gynecologists should be aware of its variations in order to offer the best screening and preventive strategies. The World Health Organization (WHO) defines sexual health as “a state of physical, emotional, mental, and social well-being in relation to sexuality, which includes sex, gender identities, and roles, sexual orientation, eroticism, pleasure, intimacy, and reproduction”2 (Table 1).
TRANSGENDER POPULATION
In this manuscript, we will focus on transgender individuals, who are a wide range of people whose sexual identity does not align with the sex they were assigned at birth. A transfemale or transwoman is a term used to identify someone who was assigned male sex at birth and identifies as a female/woman. On the other hand, transmale or transman is a person who was assigned female sex at birth and identifies as a male/ man. Many transgender people may not self-identify based on binary definitions or may identify elsewhere along the spectrum of masculine/feminine gender, or their gender identity may vary over time: gender nonbinary, gender non-conforming, gender fluid. 3 Gender dysphoria is a term used to describe the discomfort or distress that is caused by the discrepancy between their gender identity and sex assigned at birth.
It is estimated that 0.3–0.5% of the world population identifies as transgender, which represents approximately a 25million people. However, the overall world prevalence of transgenderism is difficult to estimate due to discrimination, violence, and social stigma. In the United States, approximately 0.6% of adults or 1.4million people identify as transgender. 4 Transgender people are a diverse population affected by a variety of negative health indicators.5 Moreover, they often experience discrimination in the healthcare setting and lack of access to medical personnel competent in transgender medicine.6 The World Professional Association for Transgender Health (WPATH) has published clinical guidelines for professionals who assist transgender individuals, which focus on different, if any, treatment options that include: changes in gender expression, hormone therapy to feminize or masculinize the body, surgical approach to change primary and/or secondary sex characteristics, and/or psychotherapy for purposes such as alleviating internalized transphobia, improving body image, or promoting resilience.7 The American Psychological Association, the American Psychiatric Association, and WPATH, among other organizations, have concluded that there is no single explanation for gender-variant behavior, and that gender dysphoria, by itself, does not constitute a mental disorder.7–9
Even though there has been a noticeable growth of research in transgender health in the last decade,10 screening guidelines regarding gynecologic care for transgender people are scarce in the literature.
TRANSITION OR GENDER AFFIRMATION/CONFIRMATION
GENDER-CONFIRMING THERAPIES
Cross-sex Hormones
Gender-confirming Surgical Procedures
GYNECOLOGIC CONSIDERATIONS
Gynecologic Clinical History
Gynecologic cancer screening
TRANSWOMEN GYNECOLOGIC SCREENING
Breast Cancer Screening
Cervical/Neovaginal Cancer Screening
TRANSMEN GYNECOLOGIC SCREENING
Chest (Breast) Cancer Screening
Cervical Cancer Screening
Ovarian Cancer Screening
Endometrial Cancer Screening
Urological Counseling
CONCLUSION
Cancer care for transgender individuals is a growing concern. Research into how cancer affects the transgender community, as well as screening and preventive strategies in transgender people, is imperative.50 Gynecologic oncologists may be increasingly consulted by transgender patients and should be familiar with gender-neutral forms and language, as well as patients’ reproductive organs for a correct assessment regarding cancer screening. Moreover, screening for reproductive organ malignancies should be accurate in accordance with the person's hormonal and surgical status. For individuals with familial or hereditary cancer, personalized risk estimation is challenging given the limited information currently available. Long- term multicenter studies are needed in order to promote the best screening and preventive strategies for people with non-traditional genders and sexualities.
Trinidad Labanca, Ivan Mañero, Marcelo Pannunzio
ABSTRACT
In the last several years, demand for transgender care from gynecologists has increased significantly. Transgender people comprise a diverse group who do not identify with the sex they were assigned at birth. Worldwide, it is estimated that 25million people identify as transgender. Some undergo hormonal and/or surgical treatment aiming to feminize or masculinize their bodies. Cross-sex hormone treatment for transgender women—individuals assigned as male at birth who identify themselves as women—includes exogenous estrogen and/or progestin administration in combination with anti-androgens, whereas testosterone is used for transgender men—individuals whose natal sex is women but identify themselves as men. Although it is usually rare, hormone-sensitive malignancies may arise, and long-term effects remain unknown. In addition, reconstructive surgeries may include breast augmentation and vaginoplasty (creation of a vagina) for transgender women, and chest masculinization surgery (bilateral mastectomy), and metoidioplasty (lengthening of the clitoris to create a microphallus) or phalloplasty (creation of a phallus) for transgender men. Evidence relating to breast and reproductive tract cancers in the trans population is limited and insufficient to estimate cancer prevalence, and recommendations for screening and preventive care depend on the patients’ hormonal and surgical status. Even less information exists regarding the sub-set of individuals with a genetic predisposition for these malignancies. In this review, we aimed to summarize current recommendations for gynecologists and gynecologic oncologists regarding cancer screening and personalized cancer-risk assessment in transgender people.
INTRODUCTION
The American College of Obstetrics and Gynecologists (ACOG) and the Royal College of Obstetricians and Gynecologists (RCOG) recommend that gynecologists deal with sexual health in routine clinical practice and encourage not making assumptions or judgments on patients’ sexual behavior, including relationships and sexual practices, aiming to promote sexual health as a right for every person.1 Gender diversity is an important part of sexual health, and gynecologists should be aware of its variations in order to offer the best screening and preventive strategies. The World Health Organization (WHO) defines sexual health as “a state of physical, emotional, mental, and social well-being in relation to sexuality, which includes sex, gender identities, and roles, sexual orientation, eroticism, pleasure, intimacy, and reproduction”2 (Table 1).
TRANSGENDER POPULATION
In this manuscript, we will focus on transgender individuals, who are a wide range of people whose sexual identity does not align with the sex they were assigned at birth. A transfemale or transwoman is a term used to identify someone who was assigned male sex at birth and identifies as a female/woman. On the other hand, transmale or transman is a person who was assigned female sex at birth and identifies as a male/ man. Many transgender people may not self-identify based on binary definitions or may identify elsewhere along the spectrum of masculine/feminine gender, or their gender identity may vary over time: gender nonbinary, gender non-conforming, gender fluid. 3 Gender dysphoria is a term used to describe the discomfort or distress that is caused by the discrepancy between their gender identity and sex assigned at birth.
It is estimated that 0.3–0.5% of the world population identifies as transgender, which represents approximately a 25million people. However, the overall world prevalence of transgenderism is difficult to estimate due to discrimination, violence, and social stigma. In the United States, approximately 0.6% of adults or 1.4million people identify as transgender. 4 Transgender people are a diverse population affected by a variety of negative health indicators.5 Moreover, they often experience discrimination in the healthcare setting and lack of access to medical personnel competent in transgender medicine.6 The World Professional Association for Transgender Health (WPATH) has published clinical guidelines for professionals who assist transgender individuals, which focus on different, if any, treatment options that include: changes in gender expression, hormone therapy to feminize or masculinize the body, surgical approach to change primary and/or secondary sex characteristics, and/or psychotherapy for purposes such as alleviating internalized transphobia, improving body image, or promoting resilience.7 The American Psychological Association, the American Psychiatric Association, and WPATH, among other organizations, have concluded that there is no single explanation for gender-variant behavior, and that gender dysphoria, by itself, does not constitute a mental disorder.7–9
Even though there has been a noticeable growth of research in transgender health in the last decade,10 screening guidelines regarding gynecologic care for transgender people are scarce in the literature.
TRANSITION OR GENDER AFFIRMATION/CONFIRMATION
GENDER-CONFIRMING THERAPIES
Cross-sex Hormones
Gender-confirming Surgical Procedures
GYNECOLOGIC CONSIDERATIONS
Gynecologic Clinical History
Gynecologic cancer screening
TRANSWOMEN GYNECOLOGIC SCREENING
Breast Cancer Screening
Cervical/Neovaginal Cancer Screening
TRANSMEN GYNECOLOGIC SCREENING
Chest (Breast) Cancer Screening
Cervical Cancer Screening
Ovarian Cancer Screening
Endometrial Cancer Screening
Urological Counseling
CONCLUSION
Cancer care for transgender individuals is a growing concern. Research into how cancer affects the transgender community, as well as screening and preventive strategies in transgender people, is imperative.50 Gynecologic oncologists may be increasingly consulted by transgender patients and should be familiar with gender-neutral forms and language, as well as patients’ reproductive organs for a correct assessment regarding cancer screening. Moreover, screening for reproductive organ malignancies should be accurate in accordance with the person's hormonal and surgical status. For individuals with familial or hereditary cancer, personalized risk estimation is challenging given the limited information currently available. Long- term multicenter studies are needed in order to promote the best screening and preventive strategies for people with non-traditional genders and sexualities.
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