Trans and gender-diverse people face higher risk of some cancers, and a higher risk of those cancers being missed
HPV-linked cancers – which are vaccine preventable in most cases – are a particular threat to trans people, a review study recently found.
- 31 March 2023
- 5 min read
- by Gavi Staff
A cultural predisposition to systemically constructing gender as a simple binary is likely placing trans and gender-diverse (TGD) people at elevated risk from cancer, a narrative review study recently published in JAMA Oncology suggests.
TGD needs in the "cancer care continuum" are "not optimally addressed," the study's authors conclude. "Disparities in cancer risk, needs, epidemiology and access to proper care exist."
The riskiest strains of HPV were disproportionately present in TGD populations, the researchers found.
The issue is stacked: there is evidence that trans and TGD people are less likely to be screened for cancers they may be at risk of, that they are more likely to develop certain cancers than the population at large, and that they are less likely to get adequate, informed and respectful treatment when they make contact with the medical system.
Transgender people are people whose gender identity is at odds with society's expectations based on the sex they were assigned at birth. Worldwide, they constitute an estimated 0.3-0.5% of the wider adult population. A larger umbrella group (about 0.5-4.5% of adults) identify as gender diverse.
Many trans people rely on hormone therapy and surgical interventions to better align their bodies with their gender identity and minimise the risks of gender dysphoria – a medically relevant fact. Social discrimination and violence present a significant public health risk for TGD people all over the world. Access to medical care is, in many places, fraught, not least because trans individuals can fall into the blind-spot of a system arranged according to simple biological sex. As the JAMA study's authors note "a binary male-female lens is applied to much of cancer care."
That causes a cascade of perils, beginning with risky invisibility. Non-inclusive medical structures may encourage avoidance of cancer screening, particularly for those cancers that affect the sex organs.
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TGD people who have a cervix "could avoid undergoing Papanicolaou tests because of discomfort and structural barriers such as stigma and discrimination," note the study authors. Indeed, several studies from the US and Canada showed that trans men, and TGD respondents who had been assigned female at birth, were less likely to have had a Pap smear or other cervical cancer screening in the last year than their cis woman counterparts.
Some studies reviewed suggested that TGD people were less likely to attend breast cancer screenings than cis women. But both trans men and trans women were found by a Dutch study to be significant risk of breast cancer. In a Dutch study of 2019, trans women were found to suffer a breast cancer rate 46 times higher than cis men, and three times lower than cis women. A 2017 cohort study from the US found that incidence of breast cancer "did not differ significantly from that of cisgender women" but was higher than that of cis men.
High risk of HPV-linked cancers
Those trends are life-threatening. Cervical cancer is in 90% of cases linked to infection with the human papillomavirus, a virus which also infects and can cause cancer of the anus, vagina, penis, throat, and following a vaginoplasty, neovagina. The riskiest strains of HPV were disproportionately present in TGD populations, the researchers found.
A 2018 study from the US found an equivalent rate of high-risk HPV infection of the cervix in trans men (16%) as in cis women (15.2-29%), suggesting an equivalent cancer risk across both groups.
But several studies found markedly high rates of HPV infection of the anus among trans women. A cross-sectional study from Brazil found that 60.7% of trans women sampled by anal swab were positive for high-risk HPV types. A cohort study of trans women from Peru found a similar prevalence – 58.8% – for high-risk anogenital HPV, and a clinic sample study from Italy found that 52.4% of enrolled trans women tested positive for HPV.
The implication for vaccination programmes is plain: "HPV vaccination should be routinely recommended to all children and adolescents aged 9 to 12 years and adolescents and young adults aged 13 to 26 years who have not been previously vaccinated regardless of sexual orientation or gender identity."
All of us, in short, stand at risk of HPV-linked cancer. All of us deserve access to preventive immunisation, screening and care.
Elevated risk of other cancers
HPV wasn't the only sexually-transmitted, cancer-causing virus that had a higher-than-normal presence among trans people. HIV rates tend to be higher among TGD people, and so do HIV-linked cancers like Kaposi sarcoma and non-Hodgkin's lymphoma.
There were other cancer-linked risks faced by TGD people at higher rates than their cis counterparts. "Despite some conflicting results, most studies consistently showed a high prevalence of tobacco and alcohol consumption among TGD people," the study authors write. Gender-affirming hormone therapy, too "may have possible associations with carcinogenesis," suggest the researchers. In trans women, "long-term GAHT could potentially select more aggressive or castration-resistant clone cells" possibly the risk of prostate cancer.
Increased risk of death
An analysis of the US National Cancer Database from 2003 to 2016 revealed that TGD people were more likely to die of non-Hodgkin's lymphoma, prostate cancer, and urinary bladder cancer than cis patients. A Swedish study from 2011 found an increased risk of death from neoplasms (tumours) for trans patients.
What's also clear is that trans and TGD patients have a harder time than their cis counterparts when navigating most healthcare systems. A 2014 study from Europe found that 22% of TGD people reported discrimination by health care providers; a similar study from the US found that 33% of TGD people had "negative experiences" with health workers.
"Finally, a lack of [health workers'] knowledge about TGD cancer-related issues presents a further barrier to cancer care," write the study authors.
Poor data collection is compounding trans invisibility in cancer care. The study authors complain of "a lack of sensitive and effective disaggregated, granular gender-identity data collection" and note that the paucity of data stands in the way of better understanding the needs of TGD individuals with cancer. "Collection of gender variables would be important to perform prognostic and predictive studies and to populate cancer registries."
Find the full study here – Cancer in Transgender and Gender-Diverse Persons – JAMA Oncology