Cancer screening refers to the process of looking for cancer in a patient without symptoms, with the goal of finding cancers while they are still small and localized, and therefore more likely to be cured. However, cancer screening recommendations are not the same for everyone; healthcare access and a person’s experience in the healthcare system can also be different depending on their circumstances and identity.
Members of the LGBTQ+ community often face unique challenges in a heteronormative* society where education and healthcare practice are predominantly designed for heterosexual cisgender** patients.
Challenges for LGBTQ+ patients
LGBTQ+ patients experience higher rates of adverse encounters within the healthcare system, with higher rates of harassment and mistreatment by healthcare professionals, according to Ole-Petter R. Hamnvik, MBBCh, BAO, an onco-endocrinologist and specialist in LGBTQ+ health at Dana-Farber Brigham Cancer Center.
“This harassment may lead a person to avoid healthcare centers altogether,” says Hamnvik.
Importantly, cancer screening can also be very emotionally, mentally, and physically distressing for patients in a medical system designed for and dominated by cisgender heterosexual individuals. A mammogram, for example, can be an uncomfortable and even distressing experience for trans, nonbinary, and gender nonconforming*** patients who may have distress or complicated feelings about such a test, Hamnvik notes. Being in the waiting room of a clinic or health center, where the space might be dominated by people of a certain gender, for example, can also lead to feelings of being isolated and outed.
“The reason why there are higher rates of cancer risk factors among LGBTQ+ people are multifactorial,” Hamnvik explains. “A lot of it stems from the stress that comes with belonging to a minority group: being discriminated and stigmatized. These issues are magnified for those LGBTQ+ individuals who also belong to another minority group such as people of color or people that live in poverty.”
Due to social discrimination and stigmatization, LGBTQ+ people also experience higher rates of poverty and lack of insurance because of lower rates of employment. These systemic challenges have led to lower rates of cancer screening among LGBTQ+ people.
People who are marginalized due to gender or sexual identity are also more likely to use tobacco or alcohol and are more likely to have other medical conditions, such as infections with HPV or HIV. These factors can result in a higher risk of cancer.
Cancer screening recommendations
Cancer screening recommendations can be different for cisgender patients and gender nonconforming, non-binary, or transgender patients.
Breast cancer screening is recommended for cisgender women beginning at age 40 to 45, depending on their level of individual risk (which should be discussed with a medical professional). The recommendation is the same for lesbian cisgender women.
“Lesbian cisgender women actually have more risk factors [that can lead to breast cancer] than cisgender women, like smoking, alcohol consumption, obesity, and fewer pregnancies,” says Hamnvik. “Because of those risk factors, it becomes particularly important to do those screenings.”
Trans women should be screened five years after initiation of estrogen (the hormone that transgender women may choose to take to affirm their gender), if applicable.
“It has been found that the risk of breast cancer is higher in transgender women than in cisgender men,” Hamnvik explains.
Trans men are recommended to receive the same screenings as cisgender women unless a mastectomy has been performed.
“After a mastectomy there is still some breast tissue as well,” Hamnvik says. “So although screening isn’t required, a lump or bump on the chest should still be worked up by a physician.”
Cervical cancer screening is recommended for cisgender women between 25 and 65. The idea that lesbian cisgender women are at lower risk of cervical cancer is untrue, and they should be screened as other cisgender women are, according to Hamnvik. Transgender men whose cervix have not been removed should also continue to be screened.
The cervical cancer screening procedure can be emotionally, mentally, and physically distressing, and a sensitive approach is required. As is also true for breast cancer screening, this procedure deals with a part of the body that may cause distress to a transgender man or gender nonconforming person.
“The procedure of obtaining a sample from the cervix is already uncomfortable for cisgender women, but its particularly so for transgender men because of the effects of testosterone on the vagina,” Hamnvik explains. “As we give these hormones, the lining of the vagina can become dry and uncomfortable.” This could lead to discomfort or pain during the procedure, which could deter the patient from getting screened in a timely way.
To help with that, a physician may provide a short course of vaginal estrogen. This is an option you may want to discuss with your medical provider if applicable.
Having HIV/AIDS can also lead to a higher risk of cervical cancer, and the LGBTQ+ community is disproportionately affected by HIV/AIDS.
Many cervical cancers can also be prevented with an HPV vaccine, for those that are eligible.
Prostate cancer screening guidelines for the general population are controversial because risks might outweigh benefits. There are positive and negative factors to consider when screening for this cancer, and options should be discussed with a doctor.
Everyone with a prostate can develop prostate cancer. However, some people are at lower risk. People who may choose to receive estrogen treatment, such as trans women, will see a drop in their testosterone levels. Testosterone has been found to be a driver of prostate cancer, so if you have lower testosterone levels, you are at a lower risk of prostate cancer, Hamnvik notes. Furthermore, low testosterone levels also lowers PSA levels, making the PSA test is even more inaccurate than it already is for cisgender men.
All to say: Prostate cancer screening is complicated, regardless of gender identity. Options should be discussed with a medical professional.
If a prostate exam is needed for a trans woman who has had reconstructive genital surgery, the exam should be done through the vagina, not the rectum.
Anal cancer screening is generally not recommended for the general population, but the risk factors of anal cancer include receptive anal intercourse and HIV infection. Generally, the recommended screening option is a Pap smear, but the abnormal results are complicated to analyze, according to Hamnvik.
“There is really a lack of consensus and lack of research,” he says.
Those who are eligible can reduce their risk of contracting anal cancer by getting vaccinated for HPV. Furthermore, as the risk of anal cancer is higher in those with HIV infection, HIV prevention is even more important. Many people in the LQBTQ+ community are eligible for pre-exposure prophylaxis (PrEP) for HIV.
Any symptoms from the anal area should be brought to the attention of a clinician, including symptoms such as bleeding, a mass/a lesion, and pain.
Tips for patients
Hamnvik has tips for LGBTQ+ patients in navigating the healthcare environment:
- Try to find a provider that you can trust and who has cultural competency. You may find it helpful to use provider directories such as those offered by GLMA, LGBT Cancer Network, OutCare Health, National LGBT Cancer Network, and the World Professional Association for Transgender Health (WPATH) .
- Once you find a provider you can trust, be open with your provider about your sexual attractions, histories, gender identity, past gender-affirming treatments, and any specific accommodations that you know you need. “I know this is easier said than done,” says Hamnvik. However, those factors will be put into consideration for recommended screening options.
- Ask the local LGBTQ+ community for recommendations.
- Remember: You should be expected to be treated with dignity and respect, and you should report accordingly if mistreatment happens.
This content was adapted from a virtual seminar hosted by the Eleanor and Maxwell Blum Patient and Family Resource Center at Dana-Farber Brigham Cancer Center. You can watch the full seminar below.
Remember: The cancer screening process involves risks and benefits depending on the types of cancer and each patient’s health condition, so it is recommended that patients always consult with a medical professional.
* Heteronormative refers to a world view that promotes heterosexuality as the normal or preferred sexual orientation.
** A person who is cisgender has a gender identity that corresponds with the sex the person had or was identified as having at birth.)
*** Those whose gender identity and/or expression is different from cultural expectations based on the sex they were assigned at birth.