Breast cancer screening information for trans women

Breast cancer screening for trans women will depend on:

• a client’s age
• whether she is taking gender-affirming hormones, and for how long:
  • taking gender-affirming hormones for more than five years increases breast cancer risk. Current information suggests that clients who have taken hormones for more than five years should be screened for breast cancer.
  • Trans women who have not taken gender-affirming hormones for more than five years are not at an increased risk of breast cancer, and therefore do not need to be screened.
  • whether a client has breast implants. Breast implants on their own do not increase the risk of cancer, but most trans women who have received breast implants have also taken gender-affirming hormones. Diagnostic, rather than screening, mammography is required when a client has implants.
  • whether a client has silicone breast injections. Silicone injections are illegal and pose serious health threats, but some trans women may self-inject silicone in order to alleviate gender dysphoria. Although no current evidence shows that injecting silicone can increase cancer risk, it can make cancer screening more difficult. If your client has injected silicone, discuss the risks nonjudgmentally, and explore options for breast screening. MRI along with ultrasound may be the best way to screen clients with silicone breast injections.

More evidence is needed to understand risks, benefits, intervals and screening methods for trans women. Current information and limited research suggests that trans women should be screened for breast cancer according as follows:

Tips for providing breast screening referrals to trans women

Intimate procedures that examine or expose the breasts or chest may be challenging or risky for trans women. Here are some things that you as a healthcare provider can do to make the experience easier:

Understand that many trans women have tender or dense breast tissue. This can make a mammogram difficult to read, and may make it uncomfortable or painful. It can help to let your client know that the mammogram might be uncomfortable, but that the pressure will not last long and that she can ask for the pressure to be relieved if it’s too painful. Trans women with dense breast tissue may need additional or alternate screening — such as ultrasound — if the mammogram is too difficult to read.

Be aware of the effects of gender designation on health cards. If a trans woman has a male/M designation on her health card, she is not eligible to be screened via the Ontario Breast Screening Program and will need a referral from her primary health care provider. If she has a female/F on her health card, she can self-refer to the OBSP.

Where possible, requisition the mammogram at a clinic or hospital with experience in and sensitivity training for LGBTQ populations. If you’re not sure, telephone the clinic in advance and speak to the manager or director to let them know that you are referring a trans client for testing and to make sure they have appropriate training in place.

Alert screening clinic to your trans client's needs. With your client’s consent, you can note in the file that she is trans, the name she prefers to be called (if different from the name on her health card), and her preferred gender pronouns (usually, she and her). This can be especially useful in the context of mammography clinics, where the assumption is that the majority of clients will be female — hearing a male name called out can be extremely uncomfortable and potentially socially alienating for trans women. 

Make sure that your client understands clearly:

• what will happen before, during and after the mammogram
• that the test is relatively short
• that it may be physically uncomfortable but that if it is outright painful she can request for the pressure to be lessened the test stopped altogether
• how she will receive the results

Ask only what you need to know. Although you may be curious, it’s important not to make a trans client feel as though she needs to provide an education session or extra details related to being trans (e.g., you don’t need to ask about “bottom” (genital) surgeries during a mammogram). Explain why you need to ask the questions you do (e.g., “I need to ask you whether you’ve had breast implants because you’ll need a different type of mammogram if you have implants.”).

Related, respect your trans client’s request not to have a medical student observe the appointment.

Mitigate any possible confusion that may happen when you client goes for screening at the radiology clinic or hospital. Sometimes, laboratories or lab technicians are confused by a mammogram that comes from a person identified as male on their health card. This can lead to x-rays being discounted. It can save a lot of time and effort to note on the requisition that this is a trans woman’s mammogram.