What transgender women and transfeminine people should know about prostate and testicular cancer

If you are a transgender woman or a transfeminine person, screening for prostate and testicular cancer may not be at the top of your medical to-do list, particularly if you've had gender-affirming surgery or you've been on gender-affirming hormone therapy (GAHT) for some time. But the reality is that anyone assigned male at birth can develop either of these cancers.

The good news is that early detection can increase the likelihood of favorable outcomes. Here’s what you need to know about your risk—and the latest screening recommendations—to help you get the care you need.

Knowing your risk

Research is still needed to better illustrate how often transfeminine people, including people on feminizing hormones or with a history of feminizing surgery, develop prostate and testicular cancer. Here’s what we do know:

Prostate cancer seems less common in transfeminine people than in cisgender men

Prostate cancer is the second most common cancer diagnosed in cisgender men in the United States. The American Cancer Society estimates that 1 in 8 cisgender men will be diagnosed in their lifetimes. (Cisgender refers to a person whose gender identity corresponds with the sex they were identified as having at birth.)

Certain people are at a higher risk, particularly cisgender men who are Black and/or have a family history of prostate cancer. Understanding how common prostate cancer is in transfeminine people, however, is difficult due to limited data.

"We know that testosterone can actually worsen some prostate cancers and one of the treatments for prostate cancer includes blocking the action of testosterone on the prostate," explains Christina Milano, MD, a family physician and co-founder and medical director of the Transgender Health Program at Oregon Health & Science University. It would make sense, therefore, that being on GAHT that suppresses or blocks testosterone "may actually have a benefit on that person’s likelihood of experiencing prostate cancer," she adds.

How does gender-affirming surgery play into your risk of prostate cancer?

"The creation of the vaginal canal during gender-affirming surgery does not involve removal of the prostate,” says Dr. Milano. Because the prostate is left behind for those procedures, your risk for future prostate cancer would not be eliminated. If somebody has a gender-affirming surgery that involves removal of the testes and that natural source of testosterone in the body, she adds, “that would have a beneficial impact of limiting testosterone exposure were somebody to have prostate cancer."

There is limited data on the rate of prostate cancer in transfeminine people. One large retrospective cohort study in the Netherlands published in 2020 in The Journal of Clinical Endocrinology and Metabolism found six prostate cancers when following 2,281 transgender women on hormone treatment who had visited a particular gender identity clinic between 1972 and 2016. Four of those cases were in transgender women who had undergone orchiectomy (surgery to remove the testes).

The researchers concluded that the risk of prostate cancer in transfeminine people on hormone therapy was significantly lower than the risk in cisgender men, but the risk wasn't eliminated completely.

Testicular cancer is very rare in transfeminine people, but it can happen

Testicular cancer is already relatively rare, with an estimated 1 in 250 cisgender men diagnosed in their lifetimes. When it is diagnosed, it usually occurs in young people between the ages of 15 and 34.

There have been very few reported cases of testicular cancer in transfeminine people on GAHT, but it's a possibility if you haven't had surgery to remove the testicles. (If you have had that surgery, your risk of testicular cancer is effectively reduced to zero.)

Understanding the screening guidelines

In general, screening recommendations for prostate and testicular cancer in transfeminine people follow the guidelines for cisgender men, though there are additional factors to consider.

Prostate cancer screening is something to discuss with a trusted healthcare provider

Prostate cancer screening can be done with a blood test called the prostate specific antigen (PSA) test. This measures how much of that protein is in your blood. Depending on your level, your healthcare provider (HCP) might advise further testing or a biopsy to determine if prostate cancer is actually present.

That said, there is some controversy around the usefulness of routine PSA tests in people with an average risk of prostate cancer. That's because the test can lead to unnecessary biopsies and because the cancer often progresses slowly. (There is an aggressive form that progresses more quickly.) The U.S. Preventive Services Task Force (USPSTF) and the Centers for Disease Control and Prevention recommend that people at average risk of prostate cancer discuss with their HCP whether screening is right for them. This conversation would ideally include the potential benefits, risks, and uncertainties associated with screening.

The American Cancer Society recommends starting prostate cancer screening discussions at age 50 if you're at average risk, but echoes the importance of making a cost-benefit analysis with your HCP.

Given that transfeminine people on GAHT with otherwise average risk have even lower than average risk of prostate cancer, the decision to screen will likely involve a discussion of your medical history, risk factors, and any symptoms (like new urinary problems) with your HCP. Finding a knowledgeable HCP to help you make this decision is key.

There are no recommended screening guidelines or tests for testicular cancer

When it comes to testicular cancer, the USPSTF recommends against routine screening for cisgender men, which experts would extend to transfeminine individuals, too. That said, if you have not had an orchiectomy, you may be at risk for testicular cancer. Many providers include an examination of a person’s testicles as part of a routine physical exam and often recommend that people do checks at home. It's important to see an HCP if you notice anything out of the ordinary in that area, including irregularities on the surface of your testes or any pain, swelling, or discoloration that doesn't go away, explains Milano.

What to expect from screening

Much of the advice around screening hinges on having conversations with a trusted HCP, which may not be something that all people have access to. If you don’t have a regular HCP, you can find affirming and knowledgeable providers near you by searching online databases like those from OutCare and GLMA, or asking people in your community for recommendations.

"We have to create environments where it's easy for patients to ask certain questions and have safe, comfortable dialogue around them," says Milano. "That might include saying, ‘I am a person who still has a prostate and I want to know what to do about taking care of my prostate,’ and, ‘What are symptoms of prostate illness or issues?’"

"That begins with a gender-affirming care environment where it's easy for patients to self-identity as transgender if they wish to do so, where it's comfortable and safe for them to raise those kinds of questions, and where they can have exams with people with whom they feel safe and who they trust," Milano adds.

If you and your HCP decide to move forward with prostate cancer screening, it may include both a physical exam and a PSA test. Note there is some evidence that tested PSA levels are significantly lower for transgender women, however. This means prostate cancer could be caught at a later stage. Discuss the test with your HCP.

If you've had vaginoplasty (gender-affirming surgery used to create a vulva and vagina), your provider may examine the prostate through the neovaginal canal, rather than through the rectum, explains Milano. If your HCP is concerned about testicular cancer, they will likely start with a physical exam and may order further tests based on your symptoms.

While more research is needed to understand the risk of prostate and testicular conditions in transfeminine people, the best place to start is by seeking sensitive, evidence-based care from an HCP with whom you can speak openly and comfortably.