Aug 012016
 

Welcome back to Open Minded Health Promotion! This week we’re looking at health promotion for transgender men and individuals assigned female at birth. Depending on your history some of these tips will apply more or less to you.

TransgenderPlease remember that these are specific aspects of health in addition to the standard recommendations for everyone (e.g., colonoscopy at age 50). Based on your health and your history, your doctor may have different recommendations for you. Listen to them.

All transgender men should consider…
  • Talk with their doctor about their physical and mental health
  • Practice safer sex where possible. Sexually transmitted infections can be prevented with condoms, dental dams, and other barriers. If you share sexual toys consider using condoms/barriers or cleaning them between uses.
  • Consider using birth control methods if applicable. Testosterone is not an effective method of birth control. In fact, testosterone is bad for fetuses and masculinizes them too. Non-hormonal options for birth control include condoms, copper IUDs, diaphragms and spermicidal jellies.
  • If you’re under the age of 26, get the HPV vaccine. This will reduce the chance for cervical, vaginal, anal, and oral cancers.
  • Avoid tobacco, limit alcohol, and limit/avoid other drugs. If you choose to use substances and are unwilling to stop, consider strategies to limit your risk. For example, consider participating in a clean needle program. Vaporize instead of smoke. And use as little of the drug as you can.
  • Maintain a healthy weight. While being heavy sometimes helps to hide unwanted curves, it’s also associated with heart disease and a lower quality of life.
  • Exercise regularly. Anything that gets your heart rate up and gets you moving is good for your body and mind! Weight bearing exercise, like walking and running, is best for bone health.
  • Be careful when weight lifting if you’re newly taking testosterone. Muscles grow faster than tendon, thus tendons are at risk for damage when you’re lifting until they catch up.
  • Consider storing eggs before starting testosterone if you want genetic children. Testosterone may affect your fertility. Consult a fertility expert if you need advising.
  • Seek help if you’re struggling with self injury, anorexia, or bulimia. Trans men are at higher risk than cis men for these aspects of mental health.
  • If you have unexplained vaginal bleeding, are on testosterone, and have not had a hysterectomy notify your doctor immediately. Some “breakthrough” bleeding is expected in the first few months of testosterone treatment. Once your dose is stable and your body has adapted to the testosterone you should not be bleeding. Bleeding may be benign but it may also be a sign that something more serious is going on. Contact your doctor.
  • In addition, talk with your doctor if you have pain in the pelvic area that doesn’t go away. This may also need some investigation. And s/he may be able to help relieve the pain.
  • Be as gentle as you can with binding. Make sure you allow your chest to air out because the binding may weaken that skin and put you at risk for infection. Be especially careful if you have a history of lung disease or asthma because tight binding can make it harder to breathe. You may need your inhaler more frequently if you have asthma and you’re binding. If this is the case, talk with your doctor.
  • If you’ve had genital surgery and you’re all healed from surgery: there are no specific published recommendations for caring for yourself at this point. So keep in touch with your doctor as you need to. Call your surgeon if something specific to the surgery is concerning. Continue to practice safe sex. And enjoy!
Your doctor may wish to do other tests, including…
  • Cervical cancer screening (if you have a cervix). The recommendation is every 3-5 years minimum, starting at age 21. Even with testosterone, this exam should not be painful. Talk with your doctor about your needs and concerns. Your doctor may offer a self-administered test as an alternative. Not every doctor offers a self-administered test.
  • Mammography even if you’ve had chest reconstruction. We simply don’t know what the risk of breast cancer is after top surgery because breast tissue does remain after top surgery. Once you turn 50, consider talking with your doctor about the need for mammography. In addition, if you’re feeling dysphoric discussing breast cancer then it may be helpful to remember that cis men get breast cancer too.
  • If you have not had any bottom surgery you may be asked to take a pregnancy test. This may not be intended as a transphobic question. Some medications are extremely harmful to fetuses. Hence doctors often check whether someone who can become pregnant is pregnant before prescribing. Cisgender lesbians get this question too, even if they’ve never had contact with cisgender men.

And most importantly: Take care of your mental health. We lose far too many people every year to suicide. Perhaps worse, far more struggle with depression and anxiety. Do what you need to do to take care of you. If your normal strategies aren’t working then reach out. There is help.

Want more information? You can read more from UCSF’s Primary Care Protocols and the Gay and Lesbian Medical Association.

Jun 272016
 

Welcome back to Open Minded Health Promotion! This week is all about how cisgender women who have sex with women, including lesbian and bisexual women, can maximize their health. As a reminder — these are all in addition to health promotion activities that apply to most people, like colon cancer screening at age 50.

Woman-and-woman-icon.svgAll cisgender women who have sex with women should consider…

  • Talk with their physician about their physical and mental health
  • Practice safer sex where possible to prevent pregnancy and sexually transmitted infections. Some sexually transmitted infections can be passed between women. If sexual toys are shared, consider using barriers or cleaning them between uses.
  • If under the age of 26, get the HPV vaccine. This will reduce the chance for cervical, vaginal, anal, and oral cancers.
  • Avoid tobacco, limit alcohol, and limit/avoid other drugs. If you choose to use substances and are unwilling to stop, consider using them in the safest ways possible. For example, consider vaporizing marijuana instead of smoking, or participate in a clean needle program.
  • Maintain a healthy weight. Women who have sex with women are more likely to be overweight than their heterosexual peers. Being overweight is associated with heart disease and a lower quality of life.
  • Exercise regularly. Weight bearing exercise, like walking and running, is best for bone health. But anything that gets your heart rate up and gets you moving is good for your body and mind!
  • Seek help if you’re struggling with self injury, anorexia, or bulimia. These issues are much more common in women than in men, and can be particularly challenging to deal with.
  • Consider taking folic acid supplements if pregnancy is a possibility. Folic acid prevents some birth defects.
  • Discuss their family’s cancer history with their physician.

Your physician may wish to do other tests, including…

  • Cervical cancer screening/Pap smear. All women with a cervix, starting at age 21, should get a pap smear every 3-5 years at minimum. Human papilloma virus (HPV) testing may also be included. More frequent pap smears may be recommended if one comes back positive or abnormal.
  • Pregnancy testing, even if you have not had contact with semen. Emergency situations are where testing is most likely to be urged. Physicians are, to some extent, trained to assume a cisgender woman is pregnant until proven otherwise. If you feel strongly that you do not want to get tested, please discuss this with your physician.
  • BRCA screening to determine your breast cancer risk, if breast cancer runs in your family. They may wish to perform other genetic testing as well, and may refer you to a geneticist.
  • If you’re between the ages of 50 and 74, mammography every other year is recommended. Mammography is a screening test for breast cancer. Breast self exams are no longer recommended.

One note on sexually transmitted infections… some lesbian and bisexual women may feel that they are not at risk for sexually transmitted infections because they don’t have contact with men. This is simply not true. The specific STIs are different, but there are still serious infections that can be spread from cis woman to cis woman. Infections that cis lesbians and bisexual women are at risk for include: chlamydia, herpes, HPV, pubic lice, trichomoniasis, and bacterial vaginosis (Source). Other infections such as gonorrhea, HIV, and syphilis are less likely but could still be spread. Please play safe and seek treatment if you are exposed or having symptoms.

Want more information? You can read more from the CDC, Gay and Lesbian Medical Association, and the United States Preventative Services Task Force.

Aug 102015
 

Rainbow ribbon for LGBT+ cancer awarenessGender and sexual minority health isn’t just about HIV/AIDS, sexually transmitted infections, and mental health. It’s also about cancers, and our exposures to risk factors for cancers. Why? Because everyone can get cancer, and we all need both preventative and therapeutic health care.

Cancer is not just one disease, which is why it’s been so difficult to “cure”. Cancer is when a cell mutates and grows out of control. The cells begin to invade other tissues, and can spread throughout the body. Any cell can become cancerous. And different cancers are caused by different things and have different treatments.

A recent paper, published online ahead of print, looked at the data surrounding lesbian, gay, bisexual and transgender/transsexual (LGBT) populations and cancers. They specifically looked at cancers which may be more common in LGBT communities: anal, breast, cervical, colon/rectal, endometrial, lung, and prostate cancers.

Why might these cancers be more common in LGBT communities? Perhaps because of higher levels of risk factors like obesity, smoking, and certain infections. Or perhaps because of lack of preventative health care.

But what do the data say? What data do we even have? So far it looks like we don’t have much information. Most studies about cancers don’t ask about sexual orientation or gender identity. But let’s take the data one cancer type at a time, just as the paper did…

Anal cancer is a rare cancer of the anus. It’s primarily associated with HIV infection and HPV infection. Men who have sex with men, because they are at high risk for HIV and HPV infections, are at higher risk for anal cancer. The risks for women and transgender people are unknown. The best prevention for anal cancer is the HPV vaccine and consistent use of condoms to prevent HPV and HIV infections. Screening, to catch cancers in their most treatable state, can be done through the anal pap test. However there are no guidelines for the anal pap test and its value as a screening tool is uncertain. Treatment for anal cancer can impact not only general quality of life for survivors but sexual quality of life for men who have sex with men. The effects on sexual quality of life may be under appreciated by physicians.

Breast cancer is among the most frequently diagnosed cancers in women. Unlike with anal cancer, there are no obvious risk factors beyond being a cisgender woman. There are no data on how rates of breast cancer differ between heterosexual, bisexual and lesbian women. It is thought that bisexual/lesbian women may be at higher risk of breast cancer because of high rates of smoking, alcohol use, and obesity. Lesbian/bisexual women are also less likely to carry a pregnancy. However, it’s not known if those risk factors are actually associated with higher rates of disease. There are no data on cis or trans male breast cancer. Trans women were thought to potentially be at higher risk because of the hormones they take, but data so far seem to indicate that they’re at low risk. When it comes to screening, the best screenings so far are clinical breast exams and mammography. Women who have sex with women are less likely to receive either. Once they survive a breast cancer, women who have sex with women may be at risk for sexual side effects more than heterosexual women.

Cervical cancer is a cancer that exclusively affects cisgender women, pre-op trans men and others who have a cervix. There are no data describing how the risk for cervical cancer may be different for bisexual/lesbian women and trans men. The biggest risk for cervical cancer is HPV infection. The best prevention of cervical cancer includes the HPV vaccine and the use of barriers to prevent HPV infection. For screening, pelvic exam with pap smear at a regular interval is recommended. Women who have sex with women are less likely to receive the vaccine and less likely to receive regular screenings. Anecdotal evidence suggests that the same is true for trans men. This would leave both bisexual/lesbian women and trans men at higher risk for cervical cancer, and higher risk that if there is cancer it will be discovered at a later stage. No studies have been performed examining how women who have sex with women and trans men fare after a cervical cancer diagnosis.

Colon cancer is the third most common cancer in both men and women. Preliminary studies indicate that lesbian, gay, and bisexual cisgender people are not being diagnosed with colon cancer more frequently than heterosexual people are. There are no data on trans people. However, LGB people are more likely to have risk factors like obesity, smoking, and alcohol use. On the whole, they are also less likely to receive screenings for colon cancer. The exception is gay and bisexual men, who receive colonoscopy and sigmoidoscopy more often than heterosexual men (the authors theorize that this may be because colonoscopy and sigmoidoscopy are used to diagnose difficulties with receptive anal sex). No studies have compared side effects in LGBT survivors. However, clinicians should advise men who have receptive anal sex that treatment may impact their sexual life.

Endometrial cancer is a cancer of the lining of the uterus, which can affect any individual with that lining. There are no data on lesbian, bisexual, or transgender populations nor are there recommendations for prevention and screening for endometrial cancer. Survivor outcomes are similarly murky. However the authors note that lesbian and bisexual women, because of stigma, may seek medical care later than heterosexual women. The authors advocate for a welcoming LGBT environment for patients to facilitate early detection and treatment.

Lung cancer is the leading cause of cancer death worldwide and is primarily caused by tobacco smoke. There are no direct studies of lung cancer in LGBT populations, but LGBT people are far more likely than heterosexual/cisgender people to smoke. LGBT people, as a whole, are thus at higher risk for lung cancer. While an annual screening (via low-dose CT scan) is recommended for some long term smokers, the guidelines were not intended for LGBT patients and may not be appropriate. Outcomes and side effects are unknown for LGBT people.

Prostate cancer is a cancer that exclusively affects cisgender men and transgender women (regardless of surgical status — the prostate is not removed in surgery). HIV+ men may be at lower risk for prostate cancer, though that may be an artifact of testing. The risk of prostate cancer for trans women is unknown, but is not zero. The screening test for prostate cancer, prostate specific antigen (PSA), is of limited value, but it appears that there are no differences in screening based on sexual orientation. Treatment for prostate cancer often has sexual and bowel side effects which may affect men who have sex with men differently (particularly men who prefer receptive anal sex).

Astute readers may have noticed a trend: There are not enough data. This is a huge problem in gender and sexual minority health. We just do not know enough, particularly about topics other than HIV. While some research is going on now to try to tackle these issues, it will be a while before those results come out and get validated.

So in the mean time, what is an LGBT+ person, worried about cancer, to do? You have options! You can…

  • Find a medical provider whom you feel safe and comfortable with, and make sure you come out to them. Ask them about screening schedules for you, given your own set of risk factors. Screenings will not prevent cancer, but they will allow your physician to detect cancer in its earliest, most curable stages and could save your life.
  • Exercise, achieve/maintain as healthy a weight as you can, and eat a varied diet. All of these things will help reduce your risks.
  • Quit smoking, if you currently use tobacco. Don’t start to use tobacco if you currently don’t. All forms of tobacco cause cancer, including chew and snuff.
  • Limit alcohol consumption. Drinking a lot is associated with higher rates of some cancers.
  • Be HPV-aware, and get vaccinated if you can. Use barriers in sexual encounters to prevent both HPV and HIV infection.
  • Be as familiar with your body as you can, so that you can detect changes and notify your physician.

Want to read the study for yourself? It’s publicly available!

Sep 272013
 
CC BY-NC-SA 2.0 - flickr user hyperion327

Micrograph of a breast cancer invading lung tissue.

There’s a new study out from the Netherlands examining the prevalence of breast cancer in transgender people. Gooren et al found that trans women and trans men who have had hormone therapy may be at the same level of risk for breast cancer as cis men.

Why might the risk of breast cancer be different for trans people than for cis people? Some cancers are estrogen or progesterone sensitive. That means they grow in response to those hormones. Giving estrogen to a person with estrogen-sensitive cancer would accelerate the growth of the cancer and potentially threaten their lives. Some cancers also appear more often in one sex than in the other. Breast cancer is more common in cis women than in cis men, but it still happens in cis men. How the incidence of breast cancer would be different for trans women and trans men has been a question in the trans health literature for some time.

For trans women, the development of breasts and increase in breast tissue might increase their risk for breast cancer. Trans women also receive estrogen and/or progesterone, which may affect an estrogen or progesterone sensitive cancer. This study’s authors found 8 cases of breast cancer in trans women in the medical literature, ranging from 1968 to 2013. Three of those cases appeared not to be related to hormones. The other five occurred within 5-10 years of starting hormone therapy. These cases also follow the (cis women) pattern of ductal carcinomas being the most common cancer.

For trans men, the presence of breast tissue is a risk, even after top surgery. Remember that top surgery does not remove all breast tissue! And estrogen levels continue to be at a “female” level, especially with testosterone’s ability to aromatize to estrogen. Or at least, estrogen levels continue to be at that level until an oophorectomy. Additionally, trans men may be reluctant to be screened for breast cancer because it’s deemed a “female” process and may aggravate dysphoria. 4 cases of breast cancer among trans men were found in the literature, from 2003 to 2012. The cancers were detected within 2-10 years of starting hormone therapy, and three of the four were ductal carcinomas.

The present study looked through the records of the VU University Medical Center in Amsterdam, which has records dating back to 1975. They looked at records from 1975 to 2006. The average age for starting hormones was 29, and they had an average follow-up time of 21-23 years. They were able to follow up with 3102 trans people: 2307 trans women and 795 trans men – the “classic” 3:1 ratio.

Of this sample, only 3 cases of breast cancer were reported. Two were trans women, one a trans man. One of the women had an unknown cancer which could not be proven to be from the breast. The other had an estrogen sensitive, progesterone insensitive ductal carcinoma (again, the most common form of breast cancer). The man in this sample had a benign but rare tumor, a tubular adenocarcinoma, after top surgery. The tumor was estrogen and progesterone sensitive.

Three out of 3102 is not many! That’s 0.097%. And even if you break it down by gender, 0.87% of the trans women in this study had breast cancer and 0.13% of the trans men in this study had breast cancer. Here’s another way of looking at the data: The authors calculated the incidence based on these data, per 100,000 person-years. I’ve included their 95% confidence interval in parentheses when it was disclosed. They are as follows…

  • Trans women: 4.1 (0.8-13)
  • Cis women: 154.7-170
  • Trans men: 5.9 (0.5-27.4)
  • Cis men: 1.1-1.2

In other words, if you saw 100,000 trans women in 1 year, maybe 4 of them would have breast cancer.

These data indicate that both trans men and trans women fall into the range expected for cis men for breast cancer. Given that prevalence, the authors argue that trans people of all genders should be treated under the “male” breast cancer guidelines. Risk factors for male breast cancer include: presence of the BRCA1 and BRCA2 genes, obesity, low levels of testosterone (androgen deprivation) and high levels of estrogen (estrogen exposure). Feminizing hormones automatically create two of those conditions (androgen deprivation and estrogen exposure), but so far that doesn’t seem to be increasing the rate of breast cancer in trans women. The authors also point out that testosterone may be preventative for breast cancer in trans men, also based on these data and the known risk factors for breast cancer.

Limitations of this study include the usual cautions about generalizability. This study was limited to one clinic in the Netherlands – its results may not be applicable to other countries. Especially of note is that Europe tends to use cyproterone acetate for an anti-androgen. Cyproterone acetate is not available in the United States, where spironolactone is the standard anti-androgen. The authors were also not clear about surgical status, and the presence or absence of gonads may also affect breast cancer rates. The authors also point out that their follow-up time was relatively short – an average between 21 and 23 years. But on the whole I don’t find much to criticize in their observations based on what they published.

I find these results reassuring. While some medical providers have already started thinking that their trans patients are at relatively low risk for breast cancer, there’s been little data supporting it. Data is important. Without it, we could not have the safest, evidence-based, most effective treatments we have today.

So what can you do with these data? You can keep in mind the non-gendered risk factors for breast cancer, which include:

  • Age (being over age 55)
  • Mutation in the BRCA1, BRCA2, and other genes
  • Personal or family history of breast cancer. The more closely (genetically) related the family members are, the higher the risk
  • Previous exposure to radiation in the chest area
  • Exposure to DES while in the womb
  • Drinking alcohol
  • Smoking tobacco
  • Obesity
  • Lack of exercise

As you can see, some of these risk factors are changeable. Some are not. Change the ones you can to minimize your risk. And consult your physician to figure out which screenings would be best for you. Options include breast self-exams, clinical breast exams, and mammograms.

This research article was published in the Journal of Sexual Medicine. The abstract is publicly available.

Remember: Stay healthy, stay safe, and have fun!

Jun 212013
 

Image © Kristy Peet. Used under creative commons license: CC BY 2.0A third case report of a meningioma in a trans woman has just been published.

A meningioma is a tumor of the meninges, the tissues between the skull and the brain. Most meningiomas come from the arachnoid mater, through which the cerebrospinal fluid sluggishly flows. Meningiomas are mostly (90%) benign, meaning they are not cancerous and will not spread throughout the body. Current treatment is surgery to remove the tumor, with radiation available if surgery is not possible.

There is some thought that sex hormones are a factor in the growth of meningiomas. Women are more likely to develop a meningioma than men. Like some breast tumors, meningiomas have also been found to be sensitive to estrogen and/or progesterone. Sensitivity refers to the tumor cells having receptors for certain hormones, and responding to those hormones. In the case of some estrogen-sensitive breast cancers, the estrogen increases the growth of the tumor.

This case was in Australia. The patient had been on estrogen and an anti androgen (cyproterone acetate), and had had genital surgery years before. Her tumor was benign, though sensitive to progesterone and estrogen, and was surgically removed. Unusually, her tumor came back and was removed again. She underwent radiation treatment. She is reported to have chosen to stop hormones and has made a full recovery.

Whether hormone therapy influences the growth of meningiomas is unknown. So far, the data are mixed and there is no consensus in the medical community. The other two case reports continued hormone therapy with no recurrence of the tumor. To stay on the safe side, however, the authors recommend that hormone therapy be discontinued upon diagnosis of a meningioma. They also suggest that a history of meningioma may be a contraindication for starting hormone therapy.

All individuals, trans or cis, should seek medical advice if they have any neurological symptoms. This includes symptoms associated with meningiomas such as headaches, seizures, blurred vision, double vision, weakness in arms or legs, numbness, or speech problems.

This case report was published in International Journal of Transgenderism. The abstract is publicly available.