What transgender men and transmasculine people need to know about gynecologic cancers

Knowing when to be screened for certain cancers can be confusing. Recommendations are frequently updated and it can be a challenge to keep up with the most recent guidelines. That's especially the case for transgender, gender nonconforming, and nonbinary individuals who are often left out of the research and guidelines that help patients plan their preventive care.

"We already know that trans and nonbinary people face disproportionate discrimination and stigma in seeking health care and in accessing insurance," says Halley Crissman, MD, MPH, an adjunct clinical assistant professor of obstetrics and gynecology at Michigan Medicine specializing in transgender health and gender-affirming care and director of gender-affirming care at Planned Parenthood of Michigan.

"When you think about reproductive and gynecologic care,” Dr. Crissman adds, “there are additional hurdles. These include the dysphoria of trying to seek care in a space that may be labeled as ‘women's health,’ the lack of provider knowledge, the intimate nature of much of the exam and discussion, as well as barriers related to the sex on one's insurance information."

For all of these reasons, transgender, gender nonconforming, and nonbinary people assigned female at birth may be less likely to receive timely, appropriate, and life-saving cancer screenings.

You may also be wondering if you even need these screenings if you've had gender-affirming surgery or have been on gender-affirming hormone therapy (GAHT) for some time. It can be a great help to have an informed healthcare provider (HCP) who is familiar with your specific healthcare needs and health history. They can help you understand which exams you should get, as well as when and where to get them.

Even if you don't have access to a regular HCP, there is evidence-based guidance available that can provide a path toward getting the care you need.

Cervical cancer screening for transmasculine people

Cervical cancer is cancer that occurs in the cervix, the body part that connects the vagina to the uterus. It is almost always caused by the human papillomavirus (HPV).

While it used to be the leading cause of death for people assigned female at birth in the United States, the number of deaths from cervical cancer has dropped dramatically over the last few decades. This is a result of regular screening with Pap tests, which check for any cervical cell changes that could point to precancer. It's also due in large part to increasing use of the HPV vaccine, which protects against the types of the virus that can cause cancer. Transgender men, however, are less likely to be up-to-date on their Pap tests, even though they are at risk of cervical cancer.

"What we recommend is that anyone with a cervix—regardless of gender—gets cervical cancer screening according to the national guidelines," says Crissman. These range by age, as follows:

• You should begin getting Pap tests at age 21.
• Between the ages of 21 and 29, if your Pap test results are normal, screening is recommended every three years. If results are abnormal, you may need to be screened more frequently.
• Between the ages of 30 and 65, screening guidelines depend on which tests you're getting. If you're only getting a Pap test and your results are normal, you can wait three years until your next test. If you're only getting an HPV test or you're getting a Pap test and HPV test together (called "co-testing”) and your results are normal, you can wait five years until your next test. If results are abnormal, you may need to test more frequently.

Meanwhile, anyone between the ages of 9 and 26, regardless of gender, is advised to get the HPV vaccine. This is the first step toward prevention of cervical cancer. In certain circumstances, a healthcare provider (HCP) may recommend that people up to age 45 receive the vaccine.

While masculinizing hormone therapy (which involves taking a form of testosterone) doesn't seem to impact your risk of cervical cancer, it can make it harder to get a sufficient sample when screening.

"Basically, there aren't as many cervical cells typically obtained on a Pap smear of a transmasculine person on testosterone compared to a cisgender woman," explains Crissman. If that happens, it's recommended that you go back for another screening in two to four months. (Cisgender refers to a person whose gender identity corresponds with the sex they were identified as having at birth.)

In some cases, gender-affirming surgery might affect your cervical cancer screening recommendations. If you've had a total hysterectomy, which includes removal of the uterus and cervix, your HCP may determine that you don't need to have any more Pap tests, unless you also have a history of high-grade precancerous lesions (or growths).

Ovarian cancer screening for transmasculine people

While there's no screening recommendation for ovarian cancer for people at average risk—regardless of your gender—it's important to know the common risk factors and symptoms.

Risk factors for ovarian cancer include the following:

• Being middle-aged or older (most cases of the disease occur after age 40, with half of all cases occurring in those 63 or older)
• Having a family history of certain cancers
• Being considered overweight or obese
• Having a genetic mutation on the BRCA1 or BRCA2 genes
• Having had children later in life or never having had a full-term pregnancy

If you're at a particularly high risk of ovarian cancer, you might be referred to a genetic counselor to see if surgery is appropriate to reduce your risk. Procedures might include a bilateral oophorectomy, which removes your ovaries.

Symptoms of ovarian cancer include persistent bloating, bleeding or abnormal discharge, urinary or bowel changes, pelvic pain, and difficulty eating or feeling full quickly.

Having a trusted and culturally competent HCP you can talk to about your risk factors and any new symptoms is key to helping you stay informed. Your HCP can also help ease any dysphoria, which may arise from monitoring certain body parts. (Dysphoria refers to the distress you might experience when you feel your gender identity doesn’t align with your physical or physiological characteristics.)

Endometrial cancer screening for transmasculine people

As with ovarian cancer, screening for endometrial cancer (also known as uterine cancer) is not recommended for people at average risk of the disease, regardless of your gender. Again, it comes down to knowing the risk factors and symptoms.

The classic symptom of endometrial cancer is unexplained vaginal bleeding, particularly in post-menopausal cisgender women. For that reason, it's important for any transmasculine person taking testosterone to discuss abnormal bleeding with their HCP, especially if they've stopped menstruating while using testosterone. (Bear in mind, however, that a lack of bleeding does not mean no risk, so it’s important to stay in contact with your HCP on ways to reduce your risk of endometrial cancer.)

There are a number of more common reasons you might have unexplained bleeding, such as a polyp (a small growth) or an infection. But your HCP should consider endometrial cancer if you have certain risk factors, such as if you're older, you have a family history of certain cancers, or if you're considered overweight.

"It's important to know that being overweight for a person of any gender is a risk factor for endometrial cancer. The reason is because fat tissue makes estrogen and estrogen is what drives risk of endometrial cancer," says Crissman.

Finding affirming care and asking for accommodations

It can be difficult to find evidence-based, affirming care as a transgender person, but it is possible with a little planning. Here’s how:

Research your options. Online resources like OutCare and GLMA can help you find a provider in your area who understands LGBTQIA+ needs. Crissman also suggests word-of-mouth recommendations, checking with your local LGBTQIA+ organizations, and trying Planned Parenthood. At the very least, you want to make sure that the medical office has a nondiscrimination policy and prioritizes creating a safe, affirming space for LGBTQIA+ patients.

Consider any insurance hurdles. If you're seeking gynecologic care and your health insurance has your gender listed as male, call the HCP's office ahead of time to find out if certain prior authorization or modification codes are needed to ensure that your visit is covered.

Know that you are entitled to safe, affirming care. Pelvic exams and gynecologic cancer screenings may trigger discomfort, trauma, or gender dysphoria. Your HCP should be sensitive to this and make sure that you are comfortable at every step of the process. This can include telling you what's happening throughout the exam, allowing you to self-insert the speculum (a device used to help examine the cervix), and making sure you know you can stop the pelvic exam at any point.

You can also ask for accommodations that may make you more comfortable, like anti-anxiety medication, stress-reduction strategies, a support person, or even sedation. "And there should be a chaperone in the room for all sensitive exams," says Crissman.

If you cannot do a pelvic exam during this visit, that's also okay. Your HCP should be able to address your other health needs, like contraceptive counseling or screening for sexually transmitted infections (STIs), and recommend a time for you to come back when you feel more comfortable. If they're not willing to work around your comfort level, they probably aren't the right provider for you. The key is to find someone with whom you can develop a level of comfort and trust so that, together, you can develop a plan for the care you need.