By Anisha Narsam, Neurobiology, Physiology, and Behavior, ’23

Author’s note: I hope to raise awareness about the barriers that transgender individuals face in order to obtain mammograms, and possible methods for increasing breast cancer screenings in this population. This article is meant for the general public and informs readers about some of the disparities that members of the LGBTQ community face, while also exploring methods that can be used to potentially bridge this gap in care. I chose this topic because I previously read an article about the disparities in cancer screenings in minority communities, and I wanted to research more about this topic specifically for transgender populations in relation to mammograms. Through this article, I hope readers can become more aware of how both transgender individuals and healthcare professionals lack knowledge on mammogram screening requirements, the barriers that can decrease mammogram rates, and methods that can improve breast cancer screening rates in transgender populations.

ABSTRACT

Objective: The aim is to analyze reasons for the gap in transgender breast cancer screenings, including the lack of proper screening guidelines and barriers to obtaining mammograms, and what can be done to alleviate this issue to improve healthcare for transgender individuals. 

Methods: This review analyzed primary research articles from the past three years from PubMed and Google Scholar. The sources were found with the key words “transgender breast cancer screening” and “transgender mammograms”, and were used to determine the extent of the disparity of breast cancer screenings for transgender individuals, existing knowledge of transgender mammogram requirements, barriers to obtain screenings, and methods to combat this issue. 

Results: Transgender individuals have decreased rates of breast cancer screenings compared to cisgender individuals due to healthcare workers’ lack of knowledge about transgender health and barriers for obtaining mammograms. Having more training for healthcare professionals, encouraging a more inclusive environment, and having organ inventories for patients to ensure all necessary screenings are met are a few ways to combat this issue and decrease disparities for transgender individuals to obtain these crucial mammograms. 

INTRODUCTION

Transgender individuals have disproportionately fewer mammograms than cisgender individuals [1]. According to the CDC, mammograms are pictures of the breast taken with an X-ray that physicians use to detect breast cancer [2]. By analyzing the current breast cancer screening rates of transgender individuals, understanding current knowledge of healthcare professionals on transgender health, addressing barriers that can prevent breast cancer screenings, and exploring ways to increase the number of mammograms transgender individuals obtain, this paper aims to encourage mammogram screenings to benefit transgender health [1, 3-11]. These studies are crucial for recognizing the barriers that prevent transgender individuals from getting mammograms, while also exploring the ways to counter such barriers to ensure the transgender population obtains these preventative screenings. Current research presents decreased breast cancer screening rates and lack of concrete breast cancer screening guidelines for transgender patients compared to cisgender patients [1, 9-11]. Moreover, research shows limited understanding of transgender health for healthcare workers [4-5]. One of the main barriers to obtaining mammograms is anxiety, including emotional and financial distress [3, 7, 11]. However, current research also presents potential solutions to the problem, including having more training for healthcare personnel, and having organ inventories for patients to understand each individual’s unique needs to help alleviate this issue by increasing the mammogram rates of transgender individuals [6, 8, 11]. This review focuses on current literature that provides information about access to breast cancer screenings for transgender individuals and how access can be improved.

DISCUSSION

Screening Rates and Knowledge on Screening Requirements

Transgender individuals have decreased rates of mammograms compared to cisgender individuals [1, 9-11]. Both a survey of transgender individuals from Iowa and a similar survey of transgender people from Dallas, Texas found that transgender men have lower breast cancer screening rates than cisgender females [1, 9]. However, there is variation in the percentage of transgender individuals obtaining mammograms in these different parts of the country. The Iowa study found that 75% of transgender men have obtained mammograms, a lower percentage than the 94% of cisgender women who have had mammograms [1]. On the other hand, the survey results from Texas indicate that only 40% of transgender males assigned female at birth have had mammograms at some point in their lives [9]. This demonstrates how there is variation across different parts of the country in regards to breast cancer screening rates for transgender men, although in both cases, rates are lower than that of cisgender individuals [1, 9]. These variations can be due to cultural differences in obtaining screenings, different state guidelines for screenings, or different socioeconomic statuses of individuals taking the survey that can affect whether or not they can afford their screenings [4, 11]. Moreover, researchers have also determined that rates of clinical breast exams, during which healthcare professionals use their hands to check for lumps in breast tissue, are even lower than the mammogram rates for transgender individuals [1, 12]. 

Transgender individuals also have limited knowledge of breast cancer screening requirements [9, 11]. In fact, according to researchers, over 65% of the sexual and gender minority community, which includes transgender individuals, is unaware of the screenings they require [11]. Other researchers confirm that there is a lack of knowledge in regards to the healthcare needs of transgender individuals, which translates to decreased knowledge in transgender populations themselves about the need for breast cancer screenings [8, 10]. Additionally, more than half of transgender individuals who were eligible for mammograms have not completed them which, according to researchers, demonstrates a limited understanding of organ-specific screening requirements [8]. Healthcare professionals also have limited knowledge on transgender mammogram requirements [4-5, 8].

Healthcare Professionals’ Existing Knowledge and Practices

Radiologists, genetic counselors, and healthcare staff have limited information about transgender breast cancer screening requirements and are less comfortable asking patients for their pronouns [4-5, 8]. In fact, 65% of radiologists did not recognize the importance of breast cancer screening guidelines for transgender men without chest surgery, and genetic counselors did not have the proper knowledge about the importance of breast cancer screenings for transgender women on estrogen therapy [4-5]. This demonstrates how more guidelines and protocols in relation to transgender mammograms need to be emphasized in healthcare environments [4, 11]. Both genetic counselors and radiologists agree that more research should be done to improve healthcare for transgender populations [4-5]. Genetic counselors reported in a survey feeling comfortable asking both transgender and cisgender patients about their pronouns [5]. Similarly, most radiologists claimed they felt comfortable asking patients about sex and gender identity for mammograms [4]. However, a survey of radiologists found that only 13% of physicians actually record both the sex and gender of transgender patients [4]. 

Also, in practice, when researchers observed providers and staff in another study, most healthcare professionals hesitated to ask the patient for their pronouns as they claimed they were uncomfortable and scared of offending the patient [8]. This demonstrates how although some healthcare professionals may claim to be comfortable asking about the gender and sex of patients, they may not execute this in practice, possibly because they are scared of offending the patient [4, 5, 8]. Transgender individuals may still develop breast cancer whether or not they identify with their biological sex, so it is imperative that healthcare providers ask for both gender and sex for each individual so they can obtain the preventative breast cancer screenings they require [3]. However, there can be many barriers to prevent access to such screenings [3, 7, 10-11].

Barriers and Inclusivity

Two of the main barriers for obtaining mammograms include anxiety or emotional distress associated with the appointment in transgender patients, as well as discrimination [3, 7, 10-11]. Transgender individuals have a disproportionately higher prevalence of anxiety. In an interview with one transgender individual, the patient stated that he was anxious about getting a breast cancer screening done because he did not want to stand out as the only man in a predominantly female division of the clinic, and this anxiety prevented him from getting screened [3, 7]. In fact, around half of transgender individuals do not get preventative cancer screenings because it causes them more emotional distress, on average, than these screenings do for cisgender individuals [11]. Such anxiety can also stem from the fear of being treated as their gender assigned at birth as opposed to the gender they identify as [7]. Another possible source of emotional distress comes from not having proper guidance on what screenings are recommended [4, 11].Although screening guidelines exist, there are no official nationwide screening recommendations published that can provide information on, for example, how having hormone therapy or gender-affirming surgeries can affect the types of screenings needed [4, 11]. Financial insecurities are a third source of emotional distress, with transgender individuals reporting lower incomes and health insurance coverage, causing around 50% of this population to postpone preventative cancer screenings as a result [3-4 10-11]. Moreover, transgender individuals experience higher rates of discrimination compared to cisgender groups, with around 52% of transgender individuals experiencing some type of discrimination, both during cancer screenings and for individuals who have received cancer treatment [3-4, 10]. Some examples of such discrimination include how 20% of transgender individuals were denied healthcare because they were gender-nonconforming, and how 20% of this population were also denied physician care for being transgender, which can lead to distrust in healthcare providers and a reduction in mammograms for transgender individuals [11].

Lack of inclusivity in medical settings can be another barrier for obtaining breast cancer screenings, and there can be contradicting information about what is considered inclusivity between transgender individuals and other outside populations, including researchers [3,7]. For example, based on a survey sent to radiology device companies, some of which provide the technology necessary for mammograms, researchers found that all responding companies had a third gender option of “other” when registering patients [3]. The only companies that responded were the ones that had more gender options than male and female, but the companies that did not respond may still have only two gender options [3]. Based on this information, researchers concluded that since there are more options than male and female on radiology devices, this demonstrates a more inclusive environment for transgender patients [3]. However, in an interview with one transgender individual, they mention how they feel offended when they are treated as the “other” just because they do not fit into any of the dominant gender groups, since it makes them feel alienated and unacknowledged [7]. This demonstrates how what may seem like positive language and inclusive language to some people can actually be alienating to transgender individuals in practice. Such language can, in fact, dissuade transgender individuals from obtaining mammograms, presenting another barrier to receiving the care they need [7,11]. It is crucial to combat such barriers to improve mammogram rates in transgender populations [3-4, 6-8, 11].

Methods to Improve Mammogram Rates

There are many methods that can be used to improve mammogram rates in transgender populations [3-4, 6-7, 11]. For example, training physicians and other hospital staff on methods for providing a more inclusive environment for transgender individuals can help patients feel more comfortable obtaining mammograms [3, 6, 11]. Also, providing more comfortable spaces, such as waiting rooms and changing rooms, at mammogram centers can help transgender patients feel more reassured and less anxious [11]. Another method to increase inclusivity is to have LGBTQ-specific mammogram services, or specific days the clinic is open just for LGBTQ individuals, so transgender patients would feel more reassured that the clinic is LGBTQ-friendly to ensure a more gender-affirming experience [7, 11]. It is also crucial for doctors and nurses themselves to be more understanding and listen to the patients’ concerns, since this can help build trust between the patient and provider [3, 11]. For example, one interviewed transgender patient mentioned that their physician not only affirmed their gender, but was also not forcing or chiding the patient into getting their previous gender-related preventative screenings, which made them feel a lot more comfortable and respected [7].  Once this trust is built, however, transgender patients are more likely to follow the physician’s screening recommendations, the physician provides, including for mammograms., to ensure transgender patients obtain the screenings they need [6, 9]. Physicians can also help build knowledge on mammograms for transgender individuals by enrolling their patients in a national research database that can consolidate  data about the screenings provided to patients and the outcomes of those screenings. Having this data can help healthcare professionals nationwide gain a more holistic view of the rates of certain cancers in the transgender populations, and what screenings should be emphasized for to transgender patients, as a result, to provide early detection for those specific cancers [4]. This can provide more holistic and concrete guidelines for mammograms to the entire country [4]. This database can present screening and outcome information of transgender individuals from around the country, providing a way to detect cancer rates and change how healthcare professionals treat patients based on the needs of the population [4]. Another way to ensure a more holistic understanding of each patient is to recommend organ-specific screenings, since each individual is unique, to ensure that patients do not miss any crucial cancer screenings, including mammograms [8]. In this way, healthcare professionals can ensure that no patient is left behind when it comes to obtaining such screenings. 

CONCLUSION

Overall, there are decreased amounts of breast cancer screenings done in transgender populations compared to cisgender populations, which is accompanied by a lack of knowledge of healthcare professionals on transgender screening requirements and barriers to screenings [1, 3-5, 7-11]. However, it has been shown that promoting doctor screening recommendations, having organ inventories, and providing a more supportive environment can positively combat this issue [3-4, 6-8, 11]. There are still more ways to improve screening rates by training healthcare providers and having a more inclusive environment, and further research needs to be done in this area to show the effects of such training on transgender mammogram screening rates [3, 6, 11]. Whereas some researchers argue that there is inclusivity in healthcare environments with radiology equipment having the third option for gender as “other”, transgender individuals themselves may not consider this language to be inclusive and it could instead make them feel sidelined in screening centers [3, 7]. Having more input from transgender individuals themselves on how they can be supported in breast cancer screening centers, and during the mammogram procedure, can increase comfort in healthcare environments to improve mammogram rates in this population [7]. 

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