The Trans Mammogram Gap: Large numbers of trans people aren’t receiving their recommended screenings for breast cancer. Are you?

Disclaimer: I am not a medical professional and this is not medical advice.

Zinnia JonesRoutine screenings for breast cancer using regular mammograms have enabled the earlier detection of these cancers in cis women at a stage when they are often more easily treatable and less likely to have spread. This can reduce the need for more extensive and aggressive treatment, substantially improve their prognosis, increase the likelihood of being cured, and prevent deaths from breast cancer. But far fewer people are aware of the importance of mammograms for trans people, which trans people need mammograms, and when they should receive this vital screening.

Trans women and transfeminine people who take feminizing hormone therapy as part of medical transition will grow breasts with the same tissue and structure as those of cis women, and it is possible for trans women to get breast cancer. Trans women on HRT have a higher likelihood of breast cancer than cis men, but a substantially lower likelihood than cis women (de Blok et al., 2019), possibly due to a reduced lifetime exposure to estrogen or less extensive breast tissue growth.

The UCSF Gender Affirming Health Program has recommended that trans women and transfeminine people receive mammograms every two years if they are aged 50 or over and have been on feminizing hormone therapy for at least five years (Deutsch, 2016), and other professional organizations echo this recommendation (Meggetto et al., 2019). However, the UCSF GAHP notes that clinicians may choose to begin regular mammograms earlier than this if a woman has “significant family risk factors”, such as a family history of breast cancer and suspected or known BRCA mutations.

Trans men and transmasculine people taking testosterone are not believed to be at any greater risk of breast cancer associated with their hormone therapy (Meggetto et al., 2019), and UCSF states that those who have not had a mastectomy as part of chest reconstruction surgery should follow the current mammogram screening guidelines for cisgender women. Those who have had breast reduction rather than full mastectomy are advised to continue following the guidelines for cis women, while for those who have had a mastectomy, it may not be physically possible to perform a mammogram. de Blok et al. found trans men to be substantially less likely than cis women to have breast cancer; however, in three of four cases, these trans men had already undergone mastectomy several years prior. This indicates that small amounts of remnant breast tissue following chest reconstruction still present some risk of breast cancer. Routine screening for breast cancer is not believed to be needed for those who have had chest reconstruction, and ultrasound or MRI may be used in place of a mammogram if imaging of the chest is necessary.

Overall, some trans people may be at a lower risk of breast cancer than cis women depending on their treatment history, and some trans people may not, or not yet, need to undergo the same routine mammograms as cis women. But among those trans people who are advised to have regular mammograms, how many are actually receiving them? Not nearly enough. A study published this month by Luehmann et al. (2021) examines records of mammograms among 253 eligible trans patients at an Illinois hospital, 193 assigned male and 60 assigned female, and finds that they are receiving mammograms at significantly lower rates than eligible cis women.

As a comparison, the authors cite the CDC’s 2018 NCHS statistics showing that 68.5% of cis women aged 50+ received a mammogram in the past two years. Among eligible trans women and transfeminine patients at this hospital aged 50 and over with at least five years of hormone therapy, only 47.6% had received at least one mammogram ever. Rates of on-time screening were even poorer, with a mere 7.1% receiving a mammogram within the first two years of becoming eligible. Eligible trans men and transmasculine people who were at least 50 years old and had not undergone mastectomy showed similarly low rates, with 50% receiving at least one mammogram ever, and only 22.7% receiving a mammogram within their first two years after turning 50.

Those are a lot of missed mammograms among populations who are advised to receive them regularly. The authors graphed each patient’s total years eligible screening and total mammograms received against an ideal line representing always receiving mammograms at the recommended interval of two years:

Those falling below the line are patients who have not kept up with the recommended schedule of mammograms once reaching eligibility. The horizontal grouping of dots along the very bottom of the graph represents an undesirable situation: dozens of eligible trans people at this hospital alone received zero recommended mammograms after 5, 10, or 20 years. These are missed opportunities for potentially preventing more serious illness and death. This shortfall is also reflected in the findings of Bazzi et al. (2015), reporting that trans women and trans men at a health center in Massachusetts were about half as likely as cis women to receive mammograms on the recommended schedule.

I want to emphasize that the broader public discourse and public understanding of trans people’s bodies and experiences is largely doing us no favors. There’s little reason for most of the population to understand our medical specifics, and there is still a common misconception that trans women’s breasts are all breast implants rather than any actual tissue. Increasingly, we face hostility to the idea that areas of medicine historically centering cis women are not always limited to cis women, and the recognition and inclusion of the medical needs of trans women, trans men, and nonbinary people in these areas is instead portrayed as “erasing women”.

Again, all of this takes places in the context of a real and substantial gap in regular mammograms among trans people who should be receiving them. And this misinformation couldn’t be further from the guidance of actual clinicians treating us, with UCSF GAHP stating that providers “should conduct an organ based routine cancer screening for all transgender patients in accordance with current guidelines” and “if an individual has a particular body part or organ and otherwise meets criteria for screening based on risk factors or symptoms, screening should proceed regardless of hormone use”. Kean et al. (2021) similarly state that in transgender medical care, “application of the person-specific principle of gender medicine persists: treat the organs a person has based on known effects of treatment on those organs.” That’s the biological reality so often denied by the very people who wrongly believe themselves to be defending it. The reality is that we’re in a situation where a month is a good start – awareness of this crucial and lifesaving information needs to be emphasized for much longer than that if we’re to address the dangerously low rates of mammography in the trans community.

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About Zinnia Jones

My work focuses on insights to be found across transgender sociology, public health, psychiatry, history of medicine, cognitive science, the social processes of science, transgender feminism, and human rights, taking an analytic approach that intersects these many perspectives and is guided by the lived experiences of transgender people. I live in Orlando with my family, and work mainly in technical writing.
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