Barriers to early cancer diagnosis in the trans community

Key takeaways

• There are multiple barriers for the trans community when accessing healthcare services.??
• Patient care should be individualised, and a patient’s privacy and dignity respected.?
• In a consultation, explain and justify why you may need to ask certain questions, avoid inappropriate curiosity.?
• It is a patient’s right to discuss their gender identity and their past medical or surgical history.

It is difficult to fully understand the impact of cancer on the trans community as gender identity and trans status is not well documented in existing data. However, the health inequalities among the trans community and poor experiences of healthcare services are wildly acknowledged.??

In primary care, it is important to understand the barriers to accessing healthcare for the trans community to help support change and provide better health outcomes.

Potential barriers

Stonewalls health report (2018) found that 62% of trans people said they had experienced a lack of understanding of the specific health needs of the trans population by healthcare staff. ?

Trans lives survey (2021) found that 57% of trans people reported avoiding going to the doctor when they felt unwell.??

• Trans patients may find the topics of anatomy and gender assigned at birth difficult to discuss. This can create a fear of attending healthcare appointments.?

• Members of the trans community may feel uncomfortable with certain areas of their body, making symptoms, screenings, or examinations difficult to process, which may lead to delayed presentation.?

• Patients may have anxiety around booking an appointment with a healthcare service that does not align with their gender identity or have a fear of transphobia or judgement.?

• Non-binary people tend to have the poorest experience according to GP patient data, and there can be a lack of understanding of the subgroups of the trans community among healthcare services which can lead to a reluctance for patients to engage.??

• Organisational barriers exist as invitations for national cancer screening programmes remain based on the gender the patient is registered as in their healthcare records. Individuals can be screened on request; however, they cannot access the same fail-safe mechanisms.??

• Mental health issues, previous trauma, or social isolation may also make it more difficult to access healthcare services.

The barriers described above can lead to a delay in trans patients attending healthcare appointments or screening, which can ultimately lead to a delayed cancer diagnosis.

Helpful hints

Avoid assumptions of a patient’s gender identity or anatomy, ask a patient for their pronouns, and whether they would like these documented on their medical record. Treat the patient as an individual and work with them in a way that respects their privacy and dignity.??

TransActual and OUTpatients provide useful resources for patients and healthcare staff.?

It is important to understand the concerns that members of the trans community may have when accessing healthcare services and be mindful that they may have had previous negative experiences.?

• A holistic approach and building a rapport are essential, appreciate that some topics may be distressing for patients, therefore explain and justify why you are asking certain questions.?

• Explain why you may need to ask a patient about their gender history, patients will have a better understanding of their previous treatments/surgeries. However, respect that it is a patient’s right to discuss their gender identity and their past medical or surgical history.??

• Be aware that trans patients may feel uncomfortable with a clinical examination of certain parts of the body, clearly explain the reasoning for the examination and that there is no pressure to proceed. Examinations may need to be tailored to meet the patient’s needs or avoided and alternative steps taken.??

• Consider longer appointment times and offer patients the option to bring someone with them to appointments.??

• Educate patients on the possible benefits and risks associated with screening tests or investigations so they can make an informed decision.

When discussing a potential cancer diagnosis, patients may be concerned that the next steps may involve their gender-affirming hormones being altered or stopped. It’s important to reassure them that snap decisions will not be made and stopping hormones is generally uncommon.?

A link between gender–affirming hormone therapy (GAHT) and cancer is poorly defined, but like any hormonal therapy, the risk associated with GAHT and cancer will pre–dominantly depend on other risk factors, such as pre-existing genetic risk. Be mindful that when a patient is referred to a gender identity clinic, reviewing their family history of cancer is essential, as this may affect how they are advised to transition.??

Some clinics specialise in health services for trans and non-binary people, find out what is available in your local area and signpost patients. OUTpatients provides a list of sexual health clinics in England that offer specialist services for trans and non-binary people.??

Small changes to the clinical environment in primary care such as LGBTQIA+ specific health care posters, NHS rainbow badges and gender inclusive/gender-neutral leaflets can make a significant difference.??

Practice takeaway

Our Cancer Conversation on cancer in the trans community provides a useful insight in to how primary care professionals can best support patients.??

Read our Cancer Key on reducing barriers to cervical screening in the LGBTQIA+ community, and gain insights on common barriers to cervical screening faced by LGBTQIA+ patients and practical advice on supporting them.?

Macmillan Cancer Support in partnership with OUTpatients has created a useful information page on cancer in the trans community.

Find out more

• I’m trans or non-binary, does this affect my cancer screening? | Cancer Research UK?
• Implications of hormonal carcinogenesis for transgender and gender-diverse people undergoing gender-affirming hormone therapy: an up-to-date review | BMJ oncology?