Oncology Essentials
Ellen R. Carr, RN, MSN, AOCN®—Associate Editor
Clinical Nursing Care for Transgender Patients With Cancer Nathan Levitt, RN, BSN, MA
Transgender people often face barriers in their pursuit of receiving sensitive and informed health care, and many avoid preventive care and care for lifethreatening conditions because of those obstacles. This article focuses on cancer care of the transgender patient, as well as ways that nurses and other providers can help to create a transgender-sensitive healthcare environment. At a Glance • Many impediments to health care for transgender people can lead to decreased screenings and increased cancer risks. • Although limited, research on cancer in the transgender community has concluded that malignancies related to hormone therapy are rare. • Oncology nurses require essential skills and education to provide sensitive and informed care to transgender patients. Nathan Levitt, RN, BSN, MA, is an education training consultant at Callen-Lorde Community Health Center and a staff nurse on the oncology unit at Maimonides Medical Center, both in New York, NY. The author takes full responsibility for the content of the article. The author did not receive honoraria for this work. No financial relationships relevant to the content of this article have been disclosed by the author or editorial staff. Levitt can be reached at [email protected], with copy to editor at [email protected]. Key words: transgender; clinical practice; cultural competency; transphobia; healthcare access Digital Object Identifier: 10.1188/15.CJON.362-366
A
lthough transgender people, like others, require sensitive and informed health care, fear, discriminatory treatment, and other barriers often stand in their way of receiving it. Nurses are an integral part of creating a transgender-sensitive healthcare environment, but only limited information is available about this patient population. Enhancing oncology nurses’ clinical skills when working within the transgender community will help to address health disparities and create welcoming environments.
Background Several initiatives have recognized that health disparities exist for lesbian, gay, bisexual, and transgender patients (Institute of Medicine, 2011; U.S. Department 362
of Health and Human Services, 2012, 2015). In addition, transgender individuals often face the most severe health disparities and forms of discrimination (Lambda Legal, 2010). According to the National Transgender Discrimination Survey, of which the final study sample was about 6,500 transgender and gendernonconforming people, 50% of respondents said they had had to teach their healthcare providers about transgender care (Grant et al., 2011). The survey also revealed that respondents were often denied equal treatment in doctors’ offices and hospitals (24%), in emergency rooms (13%), in mental health clinics (11%), by emergency medical technicians (5%), and in drug treatment programs (3%); in addition, 24% of transgender women and 20% of transgender men reported being refused treatment altogether (Grant et al.,
2011). Fear of stigmatization or previous negative experiences within the healthcare system resulted in 28% of transgender respondents postponing or foregoing medical care when they were sick or injured (Grant et al., 2011) (see Figure 1). Finding a healthcare provider who is knowledgeable about the needs of the transgender community is a common barrier to care (Grant et al., 2011; Lombardi, 2010; Sanchez, Sanchez, & Danoff, 2009). This population experiences high rates of physical violence (26%), sexual assault (10%–14%), attempted suicide (30%–64%), substance use (26%–53%), depression (40 % –50 %), and anxiety (40%–47%) (Clements-Nolle, Marx, & Katz, 2006; Grant et al., 2011; Hotton, Garofalo, Kuhns, & Johnson, 2013; Nemoto, Bödeker, & Iwamoto, 2011). Transgender people of color reported experiencing higher levels of discrimination than white transgender people (Grant et al., 2011). Patients may feel uncomfortable disclosing their gender identity, which can result in delayed treatment, lack of preventive care, and less care for chronic conditions (Dean et al., 2000). Understanding how patients identify is vital to improving access to care and building trust; it also affects retention in care. Figure 2 provides a glossary of transgender terms and definitions. Health care for the transgender population may include medical transition care. Although not all transgender people are interested in using hormones (e.g., estrogen, testosterone), feminizing or masculinizing regimens can help to create a better balance between gender identity and appearance. Therefore, healthcare providers must understand the effects, administration, and monitoring of these regimens, and they should also consult
June 2015 • Volume 19, Number 3 • Clinical Journal of Oncology Nursing
hormone protocols regarding administration, monitoring, follow-up, and management of comorbidities (see Table 1). Transgender people may be interested in gender-affirming surgeries, which requires providers to sensitively inquire about surgeries and provide informed pre- and postsurgical care. Female-to-male (FtM) surgery options can include breast or chest surgery (e.g., chest contouring, subcutaneous mastectomy), hysterectomy, salpingo-oophorectomy, and genital surgery (e.g., metoidioplasty or phalloplasty with or without penile or scrotal prosthesis, scrotoplasty, vaginectomy) (Unger, 2014). Male-to-female (MtF) surgery options can include breast or chest surgery (e.g., augmentation mammoplasty with implants and lipofilling), feminizing procedures (e.g., facial feminization surgery, thyroid cartilage reduction or tracheal shaving, voice surgery), and genital surgery (e.g., clitoroplasty, orchiectomy, penectomy, vaginoplasty, vulvoplasty) (Unger, 2014).
some research does exist. Cancer screening for transgender people can require a modified approach to current guidelines (see Figure 3); most screening recommendations do not include information specific or relevant to the transgender population. Transgender people are less likely to have routine cancer screenings and may not undergo testing if symptoms develop (Vogel, 2014). In addition, patients may also face discomfort with healthcare providers’ use of gendered language and documentation, providers’ lack of knowledge about surgery and hormones, gender-segregated systems, discrimination and ignorance within the healthcare system, and insensitive care (Vogel, 2014). In addition, some health insurance plans do not include coverage for gender transition; coverage for genderspecific care (e.g., for gendered cancers) may also be denied (Unger, 2014).
Cancer Care
Much of the research that exists on cancer regarding this population focuses on hormone therapy. In a long-term mortality study of transgender patients tak-
Cancer incidence rates in the transgender community are largely unknown, but
Research on Cancer in the Transgender Population
ing hormones, Asscheman et al. (2011) reported no significant difference in mortality of FtM patients compared to the general population. However, in the group of hormone-treated MtF patients, mortality was 51% higher than the general population, mainly because of nonhormone-related causes (e.g., suicide, drug abuse). Elevated lung cancer mortality rates were attributed to higher rates of tobacco use in the transgender population (Asscheman et al., 2011). Peitzmeier, Reisner, Harigopal, and Potter (2014) studied Papanicolaou (Pap) test results from 233 FtM and 3,625 female (cisgender) patients, reporting that FtM patients were 8.3 times more likely to have inadequate Pap samples when compared to female (cisgender) patients. The study asserted an association between testosterone and Pap inadequacy. FtM patients were more likely to have multiple inadequate tests and longer delays in follow-up testing because of possible changes caused by testosterone and provider or patient discomfort with the examination (Peitzmeier et al., 2014). Unger (2015) reported that, in a survey of 141 obstetrics and gynecology providers, only 35% (n = 49 of 139)
75 65
Percentage
60 45
51 45 30
30
32
27 21
20
16
15
8
12
11
15
11
8
4
0 Was unaware of my health needs
Treated me differently
Provided worse Refused to care care for me
Used harsh language
Blamed me for Used excessive my health status precautions
Was physically rough
Type of Discrimination or Substandard Care Transgender and gender-nonconforming people Gay, lesbian, and bisexual people
FIGURE 1. Discrimination and Substandard Care Demonstrated by Healthcare Professionals and Experienced by Transgender and Gender-Nonconforming People Versus Gay, Lesbian, and Bisexual People Note. From When Health Care Isn’t Caring: Lambda Legal’s Survey on Discrimination Against LGBT People and People Living With HIV, by Lambda Legal, 2010. Retrieved from http://www.lambdalegal.org/sites/default/files/publications/downloads/whcic-report_when-health-care-isnt-caring.pdf. Copyright 2010 by Lambda Legal. Adapted with permission. Clinical Journal of Oncology Nursing • Volume 19, Number 3 • Oncology Essentials
363
u Cisgender: People whose gender identity and gender expression
u Transition, gender
affirmation: The process that people go through as they change their gender expression and physical appearance to align with their gender identity. A transition may occur during a period of time and may include coming out to family, friends, coworkers, and others; changing one’s name, pronoun, and/or sex designation on legal documents; and seeking medical intervention (e.g., hormones, surgery).
align with their assigned sex at birth (i.e., the sex listed on the birth certificate). u Gender
affirmation surgery: People with gender dysphoria may or may not have surgery, and, if they have surgery, they may have one or more types of surgery, depending on their circumstances. “Sex reassignment surgery” is increasingly falling into disuse because many people find the term offensive. Many consider “sex change,” “sex change operation,” “sex change surgery,” “pre-op,” and “post-op” to be pejorative; therefore, these terms should be avoided.
u Gender
identity: A person’s innate, deeply felt psychological identification as a man, woman, or something else, which may or may not correspond to the person’s external body or assigned sex at birth (i.e., the sex listed on the birth certificate).
u Transman: Refers to someone who was identified female at birth but
who identifies and portrays his gender as male. Alternate terms include “affirmed male,” “gender-affirmed male,” “FtM,” and “man.” u Transsexual: People whose gender identity differs from their as-
signed sex at birth (i.e., the sex listed on the birth certificate). Use of the term “transsexual” remains strong in the medical community because of the prior use of the diagnosis “transsexualism” (later changed to “gender identity disorder”) in the Diagnostic and Statistical Manual of Mental Disorders. Clinicians should refrain from using the term “transsexual” unless and until they are sure that it is a term their patients are comfortable with.
u Sex: In a dichotomous scheme, the designation of a person at birth
as either male or female based on his or her anatomy (i.e., genitalia and reproductive organs) and biology (i.e., chromosomes and hormones). u Transgender: An umbrella term for people whose gender identity
u Transwoman: Generally refers to someone who was identified male
at birth but who identifies and portrays her gender as female. Alternate terms include “affirmed female,” “gender-affirmed female,” “MtF,” and “woman.”
and gender expression differs from their assigned sex at birth (i.e., the sex listed on the birth certificate). Use “transgender,” not “transgendered.”
FIGURE 2. Selected Transgender Terms and Definitions Note. Based on information from Fenway Health, 2010.
were comfortable with caring for MtF patients, and 29% (n = 41 of 141) were comfortable with caring for FtM patients. About 59% (n = 82 of 138) did not know the recommendations regarding breast
cancer screening for this population (Unger, 2015). Perrone et al. (2009) studied the effects of long-term testosterone on the endometrium of FtM patients and reported
TABLE 1. Effects of Hormones in FtM and MtF Transsexual People Effect
Onset (months)
Maximum (years)
Masculinizing Effects in FtM Transsexual People Receiving Testosterone Androgenic hair loss (scalp) Cessation of menses Clitoral enlargement Deepening of voice Facial hair Fat redistribution Increased muscle mass Skin oiliness and acne Vaginal atrophy
6–12 2–6 3–6 6–12 6–12 1–6 6–12 1–6 3–6
– – 1–2 1–2 4–5 2–5 2–5 1–2 1–2
Feminizing Effects in MtF Transsexual People Receiving Estrogen and Anti-Androgen Breast growth Decreased erections Decreased muscle mass and strength Decreased sperm production Decreased testicular volume Softening of skin Voice changes
3–6 1–3 3–6 – 3–6 3–6 –
2–3 3–6 1–2 >3 2–3 – –
FtM—female-to-male; MtF—male-to-female
Note. From “Endocrine Treatment of Transsexual Persons: An Endocrine Society Clinical Practice Guideline,” by W.C. Hembree, P. Cohen-Kettenis, H.A. Delemarre-van de Waal, L.J. Gooren, W.J. Meyer III, N.P. Spack, . . . V.M. Montori, 2009, Journal of Clinical Endocrinology and Metabolism, 94, p. 3145. Copyright 2009 by the Endocrine Society. Adapted with permission. 364
no evidence that testosterone increased or reduced the risk of cancer. However, atrophic effects of androgen on the endometrium and a possible risk of polycystic ovarian syndrome can occur (Perrone et al., 2009). Healthcare providers for patients with estrogen receptor–positive cancers may need to discuss contraindications for testosterone therapy because a portion of administered testosterone can be aromatized to estradiol. Providers must approach this topic in a sensitive manner, understanding that such discussion may be difficult for the patient. Urban, Teng, and Kapp (2011) reported a case of uterine cancer in one FtM patient and a case of cervical cancer in another FtM patient; both patients were on testosterone, and their malignancies were detected during gender reassignment surgery. Malignancies may go undetected when patients do not have regular, appropriate gynecologic care. Patients may also be uncomfortable continuing with oncology care associated with their birth gender (Urban et al., 2011). Hage, Dekker, Karim, Verheijen, and Bloemena (2000) reported two cases of ovarian cancer in FtM patients taking androgens, and they recommended simultaneous salpingo-oophorectomy in transgender men undergoing hysterectomy during gender-affirming therapy.
June 2015 • Volume 19, Number 3 • Clinical Journal of Oncology Nursing
In a review of the literature, Mueller and Gooren (2008) found that in a study following 2,200 MtF patients for more than 30 years, no breast cancer cases were reported. Estrogen alone appears to pose no increased risk of breast carcinomas and may be safer than estrogen plus progesterone therapy (Mueller & Gooren, 2008). In addition, one case of breast cancer was diagnosed in an FtM patient on testosterone therapy; the cancer was detected after chest surgery (Burcombe, Makris, Pittam, & Finer, 2003). Contradicting views exist of androgens as a risk factor or as protection against cancer development. Mueller and Gooren (2008) also observed that three cases of prostate cancer were diagnosed in MtF patients aged younger than 50 years taking estrogen; however, whether the cancer was estrogen sensitive or whether the malignancy was present prior to estrogen administration is unclear. Although the prostate becomes atrophic with androgen suppression, a cancer risk still exists. Unger (2014) recommended that MtF patients who have not had a vaginoplasty be evaluated by annual rectal examination after age 50 years. However, patients with a created
neovagina may require transvaginal palpation for adequate assessment (Unger, 2014). With prolonged estrogen exposure, prostate-specific antigen levels may be falsely low (Epstein, 1993). Brown and Jones (2015) examined the incidence of breast cancer among 5,135 transgender veterans on hormones. Ten cases of breast cancer were confirmed, including seven in FtM patients and two in MtF patients. The authors concluded that enough evidence did not exist to support a connection between crossgender hormones and breast cancer. However, Brown and Jones (2015) recommended that healthcare providers demonstrate more sensitivity and increase their knowledge about transgender care. For example, this population has many risk factors for breast cancer, including a transwoman’s long-term exposure to estrogen, testosterone converting to estradiol, and remaining breast tissue after a transman’s chest surgery (Unger, 2014). Evidence from long-term studies has concluded that malignancies related to hormone therapy are rare. Transitionrelated care is important to the health of many in the transgender population. Cancer rates related to decreased rates of
Screen transgender or transsexual people who have not used cross-sex hormones or had gender-affirming surgery using the same criteria and risk parameters as for people of their natal sex. Transmen (Past or Current Hormone Use) • Breast cancer: Perform an annual chest wall and axillary examination. Breast cancer screening using mammography should also take place as for natal females; it is not needed following chest reconstruction but should be considered if only a reduction was performed. • Cervical cancer: After total hysterectomy, if the individual has a prior history of high-grade cervical dysplasia or cervical cancer, do annual Papanicolaou (Pap) smear of vaginal cuff until three normal tests are documented, then continue to perform Pap smear every two to three years. • Cervical cancer if ovaries were removed, but uterus and cervix remain intact: Follow Pap smear guidelines for natal females, but deferring is an option if individual has no history of genital sexual activity. Inform pathologist of current or prior testosterone use; cervical atrophy can mimic dysplasia. • No hysterectomy: Follow published recommended guidelines for natal females (grade C). • Uterine cancer: Evaluate spontaneous vaginal bleeding in the absence of a mitigating factor (e.g., missed testosterone doses, excessive
screening in this population may be the result of discrimination; understanding the impact of fear on screening rates is an important research priority. Discussing reproductive health concerns should be a part of transgender health care, particularly when it relates to oncology care. Transgender populations have fertility concerns that are often unaddressed by providers. Transgender men may need to discuss cessation of testosterone if interested in becoming pregnant. Transgender women may need to use sperm banking services because of estrogen’s possible effect on sperm production (Wallace, Blough, & Kondapalli, 2014).
Implications for Practice and Conclusions Nurses play an important role in transgender health promotion and cancer screening. For example, nurses should ask patients how they identify their gender, name, and pronoun. Transgender affirmative language can help to increase screenings, particularly those that are related to gendered cancers. Assessment skills should include knowing how and
testosterone dosing leading to increased estrogen levels, weight changes, thyroid disorders) as for postmenopausal natal females. Consider hysterectomy if fertility is not an issue, patient is aged 40 years or older, and health will not be adversely affected by surgery. • Follow standard screening recommendations for other cancers. Transwomen (Past or Current Hormone Use) • Breast cancer: Perform breast cancer screening using mammography in patients aged 50 years or older with additional risk factors (e.g., estrogen and progestin use of more than five years, positive family history, body mass index of 35 or greater). • Prostate cancer: Prostate-specific antigen (PSA) is falsely low in an androgen-deficient setting, even in the presence of cancer; only consider PSA screening in high-risk patients. Use a digital rectal examination to evaluate the prostate in all transwomen (grade C). • Pap smears in neovaginas are not indicated; the neovagina is lined with keratinized epithelium and cannot be evaluated with a Pap smear. Perform periodic visual inspection with a speculum, looking for genital warts, erosions, and other lesions. If a sexually transmitted infection is suspected, do a culture swab, not polymerase chain reaction. Neovaginal walls are usually skin, not mucosa; when it is mucosa, it is urethral or colon mucosa. • Follow standard screening recommendations for other cancers.
FIGURE 3. Cancer Screening Guidelines for Transgender or Transsexual People Note. From “Primary Care Protocol for Transgender Patient Care,” by the Center of Excellence for Transgender Health, 2011. Retrieved from http://transhealth.ucsf.edu/trans?page=protocol-00-00. Copyright 2011 by the Center of Excellence for Transgender Health. Adapted with permission. Clinical Journal of Oncology Nursing • Volume 19, Number 3 • Oncology Essentials
365
Journal Articles American Journal of Nursing “Lesbian, Gay, Bisexual, and Transgender Health: Is Nursing Still in the Closet?” http://bit.ly/1GZKlFV
ship resources, end-of-life care, and referrals. Education is an essential foundation for nurses, particularly within the field of oncology, and it promotes the delivery of excellent transgender affirmative care.
Nursing Made Incredibly Easy “Caring for Transgender Patients” http://bit.ly/1IONxWZ
References
Online Resources Callen-Lorde Community Health Center Transgender Health Services http://bit.ly/1RdHj6o Gay and Lesbian Medical Association Healthy People 2010: A Companion Document for Lesbian, Gay, Bisexual, and Transgender (LGBT) Health http://bit.ly/1H1ADWa Joint Commission Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community http://bit.ly/1P0Zpdl World Professional Association for Transgender Health Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People http://bit.ly/1pwKKpd
FIGURE 4. Transgender Care Resources for Healthcare Providers why to ask about patients’ history of feminizing and masculinizing interventions. The language used during physical examinations should not be based on the gender patients were assigned at birth, but instead on how patients identify their body and gender. Assessment should be sensitive to degendering the treatment, appropriate clinical screening, and the language of cancer (e.g., avoiding terms like “women’s cancer” and “men’s cancer”). Body parts of all genders may be different because of cancer-related surgeries and treatment. A number of resources regarding the care of transgender people are available (see Figure 4). The oncology healthcare team, with oncology nurses as essential team members, can greatly improve the clinical care of members of the transgender population. Challenges for the transgender population include establishing care with supportive and sensitive providers, as well as gaining effective access to transgendersensitive cancer support groups, survivor366
Asscheman, H., Giltay, E.J., Megens, J.A., de Ronde, W.P., van Trotsenburg, M.A., & Gooren, L.J. (2011). A long-term follow-up study of mortality in transsexuals receiving treatment with cross-sex hormones. European Journal of Endocrinology, 164, 635–642. doi:10.1530/EJE-10-1038 Brown, G.R., & Jones, K.T. (2015). Incidence of breast cancer in a cohort of 5,135 transgender veterans. Breast Cancer Research and Treatment, 149, 191–198. doi:10.1007/s10549-014-3213-2 Burcombe, R.J., Makris, A., Pittam, M., & Finer, N. (2003). Breast cancer after bilateral subcutaneous mastectomy in a female-to-male trans-sexual. Breast, 12, 290–293. doi:10.1016/S0960 -9776(03)00033-X Clements-Nolle, K., Marx, R., & Katz, M. (2006). Attempted suicide among transgender persons: The influence of genderbased discrimination and victimization. Journal of Homosexuality, 51, 53–69. doi:10.1300/j082v51n03_04 Dean, L., Meyer, I.H., Robinson, K., Sell, R.L., Sember, R., Silenzio, V.M.B., . . . Xavier, J. (2000). Lesbian, gay, bisexual, and transgender health: Findings and concerns. Journal of the Gay and Lesbian Medical Association, 4, 101–151. Epstein, J.I. (1993). PSA and PAP as immunohistochemical markers in prostate cancer. Urologic Clinics of North America, 20, 757–770. Fenway Health. (2010). Glossary of gender and transgender terms. Retrieved from http://www.lgbthealtheducation .org/wp-content/uploads/Handout_7-C _Glossary_of_Gender_and_Transgender _Terms__fi.pdf Grant, J.M., Mottet, L.A., Tanis, J., Harrison, J., Herman, J.L., & Keisling, M. (2011). Injustice at every turn: A report of the National Transgender Discrimination Survey. Retrieved from http://www.the taskforce.org/static_html/downloads /reports/reports/ntds_full.pdf Hage, J.J., Dekker, J.J., Karim, R.B., Verheijen, R.H., & Bloemena, E. (2000). Ovarian cancer in female-to-male transsexuals: Report of two cases. Gynecologic Oncology, 76, 413–415. Hotton, A.L., Garofalo, R., Kuhns, L.M., &
Johnson, A.K. (2013). Substance use as a mediator of the relationship between life stress and sexual risk among young transgender women. AIDS Education and Prevention, 25, 62–71. doi:10.1521/ aeap.2013.25.1.62 Institute of Medicine. (2011). The health of lesbian, gay, bisexual, and transgender people: Building a foundation for better understanding. Washington, DC: National Academies Press. Lambda Legal. (2010). When health care isn’t caring: Lambda Legal’s survey on discrimination against LGBT people and people living with HIV. Retrieved from http://www.lambdalegal .org/sites/default/files/publications/ downloads/whcic-report_when-health -care-isnt-caring.pdf Lombardi, E. (2010). Transgender health: A review and guidance for future research—Proceedings from the Summer Institute at the Center for Research on Health and Sexual Orientation, University of Pittsburgh. International Journal of Transgenderism, 12, 211–229. doi:10 .1080/15532739.2010.544232 Mueller, A., & Gooren, L. (2008). Hormonerelated tumors in transsexuals receiving treatment with cross-sex hormones. European Journal of Endocrinology, 159, 197–202. doi:10.1530/EJE-08-0289 Nemoto, T., Bödeker, B., & Iwamoto, M. (2011). Social support, exposure to violence and transphobia, and correlates of depression among male-to-female transgender women with a history of sex work. American Journal of Public Health, 101, 1980–1988. doi:10.2105/AJPH.2010 .197285 Peitzmeier, S.M., Reisner, S.L., Harigopal, P., & Potter, J. (2014). Female-to-male patients have high prevalence of unsatisfactory Paps compared to non-transgender females: Implications for cervical cancer screening. Journal of General Internal Medicine, 29, 778–784. doi:10.1007/ s11606-013-2753-1 Perrone, A.M., Cerpolini, S., Maria Salfi, N.C., Ceccarelli, C., De Giorgi, L.B., Formelli, G., . . . Meriggiola, M.C. (2009). Effect of long-term testosterone administration on the endometrium of female-to-male (FtM) transsexuals. Journal of Sexual Medicine, 6, 193–200. doi:10.1111/j.1743-6109.2009.01380.x Sanchez, N.F., Sanchez, J.P., & Danoff, A. (2009). Health care utilization, barriers to care, and hormone usage among male-to-female transgender persons in New York City. American Journal of
June 2015 • Volume 19, Number 3 • Clinical Journal of Oncology Nursing
Public Health, 99, 713–719. doi:10.2105/ AJPH.2007.132035 Unger, C.A. (2014). Care of the transgender patient: The role of the gynecologist. American Journal of Obstetrics and Gynecology, 210, 16–26. doi:10.1016/j .ajog.2013.05.035 Unger, C.A. (2015). Care of the transgender patient: A survey of gynecologists’ current knowledge and practice. Journal of Women’s Health, 24, 114–118. doi:10.1089/jwh.2014.4918 Urban, R.R., Teng, N.N., & Kapp, D.S. (2011). Gynecologic malignancies in female-to-male transgender patients: The need of original gender surveillance. American Journal of Obstetrics and Gynecology, 204, e9–e12. doi:10.1016/j .ajog.2010.12.057 U.S. Department of Health and Human
Services. (2012). U.S. Department of Health and Hu man Ser vices recommended actions to improve the health and well-being of lesbian, gay, bisexual, and transgender communities. Retrieved from http://www.hhs.gov/lgbt/resources /reports/health-objectives-2011.html U.S. Department of Health and Human Services. (2015). Healthy People 2020: Lesbian, gay, bisexual, and transgender health. Retrieved from http://w w w.healthy
people.gov/2020/topicsobjectives2020/ overview.aspx?topicid=25 Vogel, L. (2014). Screening programs overlook transgender people. Canadian Medical Association Journal, 186, 823. doi:10.1503/cmaj.109-4839 Wallace, S.A., Blough, K.L., & Kondapalli, L.A. (2014). Fertility preservation in the transgender patient: Expanding oncofertility care beyond cancer. Gynecological Endocrinology. Advance online publication.
Do You Have an Interesting Topic to Share? Oncology Essentials provides readers with a brief summary of oncology nursing basics. Length should be no more than 1,000–1,500 words, exclusive of tables, figures, insets, and references. If interested, contact Associate Editor Erin Hartnett, DNP, APRN-BC, CPNP, at [email protected].
Clinical Journal of Oncology Nursing • Volume 19, Number 3 • Oncology Essentials
367
Copyright of Clinical Journal of Oncology Nursing is the property of Oncology Nursing Society and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Ellen R. Carr, RN, MSN, AOCN®—Associate Editor
Clinical Nursing Care for Transgender Patients With Cancer Nathan Levitt, RN, BSN, MA
Transgender people often face barriers in their pursuit of receiving sensitive and informed health care, and many avoid preventive care and care for lifethreatening conditions because of those obstacles. This article focuses on cancer care of the transgender patient, as well as ways that nurses and other providers can help to create a transgender-sensitive healthcare environment. At a Glance • Many impediments to health care for transgender people can lead to decreased screenings and increased cancer risks. • Although limited, research on cancer in the transgender community has concluded that malignancies related to hormone therapy are rare. • Oncology nurses require essential skills and education to provide sensitive and informed care to transgender patients. Nathan Levitt, RN, BSN, MA, is an education training consultant at Callen-Lorde Community Health Center and a staff nurse on the oncology unit at Maimonides Medical Center, both in New York, NY. The author takes full responsibility for the content of the article. The author did not receive honoraria for this work. No financial relationships relevant to the content of this article have been disclosed by the author or editorial staff. Levitt can be reached at [email protected], with copy to editor at [email protected]. Key words: transgender; clinical practice; cultural competency; transphobia; healthcare access Digital Object Identifier: 10.1188/15.CJON.362-366
A
lthough transgender people, like others, require sensitive and informed health care, fear, discriminatory treatment, and other barriers often stand in their way of receiving it. Nurses are an integral part of creating a transgender-sensitive healthcare environment, but only limited information is available about this patient population. Enhancing oncology nurses’ clinical skills when working within the transgender community will help to address health disparities and create welcoming environments.
Background Several initiatives have recognized that health disparities exist for lesbian, gay, bisexual, and transgender patients (Institute of Medicine, 2011; U.S. Department 362
of Health and Human Services, 2012, 2015). In addition, transgender individuals often face the most severe health disparities and forms of discrimination (Lambda Legal, 2010). According to the National Transgender Discrimination Survey, of which the final study sample was about 6,500 transgender and gendernonconforming people, 50% of respondents said they had had to teach their healthcare providers about transgender care (Grant et al., 2011). The survey also revealed that respondents were often denied equal treatment in doctors’ offices and hospitals (24%), in emergency rooms (13%), in mental health clinics (11%), by emergency medical technicians (5%), and in drug treatment programs (3%); in addition, 24% of transgender women and 20% of transgender men reported being refused treatment altogether (Grant et al.,
2011). Fear of stigmatization or previous negative experiences within the healthcare system resulted in 28% of transgender respondents postponing or foregoing medical care when they were sick or injured (Grant et al., 2011) (see Figure 1). Finding a healthcare provider who is knowledgeable about the needs of the transgender community is a common barrier to care (Grant et al., 2011; Lombardi, 2010; Sanchez, Sanchez, & Danoff, 2009). This population experiences high rates of physical violence (26%), sexual assault (10%–14%), attempted suicide (30%–64%), substance use (26%–53%), depression (40 % –50 %), and anxiety (40%–47%) (Clements-Nolle, Marx, & Katz, 2006; Grant et al., 2011; Hotton, Garofalo, Kuhns, & Johnson, 2013; Nemoto, Bödeker, & Iwamoto, 2011). Transgender people of color reported experiencing higher levels of discrimination than white transgender people (Grant et al., 2011). Patients may feel uncomfortable disclosing their gender identity, which can result in delayed treatment, lack of preventive care, and less care for chronic conditions (Dean et al., 2000). Understanding how patients identify is vital to improving access to care and building trust; it also affects retention in care. Figure 2 provides a glossary of transgender terms and definitions. Health care for the transgender population may include medical transition care. Although not all transgender people are interested in using hormones (e.g., estrogen, testosterone), feminizing or masculinizing regimens can help to create a better balance between gender identity and appearance. Therefore, healthcare providers must understand the effects, administration, and monitoring of these regimens, and they should also consult
June 2015 • Volume 19, Number 3 • Clinical Journal of Oncology Nursing
hormone protocols regarding administration, monitoring, follow-up, and management of comorbidities (see Table 1). Transgender people may be interested in gender-affirming surgeries, which requires providers to sensitively inquire about surgeries and provide informed pre- and postsurgical care. Female-to-male (FtM) surgery options can include breast or chest surgery (e.g., chest contouring, subcutaneous mastectomy), hysterectomy, salpingo-oophorectomy, and genital surgery (e.g., metoidioplasty or phalloplasty with or without penile or scrotal prosthesis, scrotoplasty, vaginectomy) (Unger, 2014). Male-to-female (MtF) surgery options can include breast or chest surgery (e.g., augmentation mammoplasty with implants and lipofilling), feminizing procedures (e.g., facial feminization surgery, thyroid cartilage reduction or tracheal shaving, voice surgery), and genital surgery (e.g., clitoroplasty, orchiectomy, penectomy, vaginoplasty, vulvoplasty) (Unger, 2014).
some research does exist. Cancer screening for transgender people can require a modified approach to current guidelines (see Figure 3); most screening recommendations do not include information specific or relevant to the transgender population. Transgender people are less likely to have routine cancer screenings and may not undergo testing if symptoms develop (Vogel, 2014). In addition, patients may also face discomfort with healthcare providers’ use of gendered language and documentation, providers’ lack of knowledge about surgery and hormones, gender-segregated systems, discrimination and ignorance within the healthcare system, and insensitive care (Vogel, 2014). In addition, some health insurance plans do not include coverage for gender transition; coverage for genderspecific care (e.g., for gendered cancers) may also be denied (Unger, 2014).
Cancer Care
Much of the research that exists on cancer regarding this population focuses on hormone therapy. In a long-term mortality study of transgender patients tak-
Cancer incidence rates in the transgender community are largely unknown, but
Research on Cancer in the Transgender Population
ing hormones, Asscheman et al. (2011) reported no significant difference in mortality of FtM patients compared to the general population. However, in the group of hormone-treated MtF patients, mortality was 51% higher than the general population, mainly because of nonhormone-related causes (e.g., suicide, drug abuse). Elevated lung cancer mortality rates were attributed to higher rates of tobacco use in the transgender population (Asscheman et al., 2011). Peitzmeier, Reisner, Harigopal, and Potter (2014) studied Papanicolaou (Pap) test results from 233 FtM and 3,625 female (cisgender) patients, reporting that FtM patients were 8.3 times more likely to have inadequate Pap samples when compared to female (cisgender) patients. The study asserted an association between testosterone and Pap inadequacy. FtM patients were more likely to have multiple inadequate tests and longer delays in follow-up testing because of possible changes caused by testosterone and provider or patient discomfort with the examination (Peitzmeier et al., 2014). Unger (2015) reported that, in a survey of 141 obstetrics and gynecology providers, only 35% (n = 49 of 139)
75 65
Percentage
60 45
51 45 30
30
32
27 21
20
16
15
8
12
11
15
11
8
4
0 Was unaware of my health needs
Treated me differently
Provided worse Refused to care care for me
Used harsh language
Blamed me for Used excessive my health status precautions
Was physically rough
Type of Discrimination or Substandard Care Transgender and gender-nonconforming people Gay, lesbian, and bisexual people
FIGURE 1. Discrimination and Substandard Care Demonstrated by Healthcare Professionals and Experienced by Transgender and Gender-Nonconforming People Versus Gay, Lesbian, and Bisexual People Note. From When Health Care Isn’t Caring: Lambda Legal’s Survey on Discrimination Against LGBT People and People Living With HIV, by Lambda Legal, 2010. Retrieved from http://www.lambdalegal.org/sites/default/files/publications/downloads/whcic-report_when-health-care-isnt-caring.pdf. Copyright 2010 by Lambda Legal. Adapted with permission. Clinical Journal of Oncology Nursing • Volume 19, Number 3 • Oncology Essentials
363
u Cisgender: People whose gender identity and gender expression
u Transition, gender
affirmation: The process that people go through as they change their gender expression and physical appearance to align with their gender identity. A transition may occur during a period of time and may include coming out to family, friends, coworkers, and others; changing one’s name, pronoun, and/or sex designation on legal documents; and seeking medical intervention (e.g., hormones, surgery).
align with their assigned sex at birth (i.e., the sex listed on the birth certificate). u Gender
affirmation surgery: People with gender dysphoria may or may not have surgery, and, if they have surgery, they may have one or more types of surgery, depending on their circumstances. “Sex reassignment surgery” is increasingly falling into disuse because many people find the term offensive. Many consider “sex change,” “sex change operation,” “sex change surgery,” “pre-op,” and “post-op” to be pejorative; therefore, these terms should be avoided.
u Gender
identity: A person’s innate, deeply felt psychological identification as a man, woman, or something else, which may or may not correspond to the person’s external body or assigned sex at birth (i.e., the sex listed on the birth certificate).
u Transman: Refers to someone who was identified female at birth but
who identifies and portrays his gender as male. Alternate terms include “affirmed male,” “gender-affirmed male,” “FtM,” and “man.” u Transsexual: People whose gender identity differs from their as-
signed sex at birth (i.e., the sex listed on the birth certificate). Use of the term “transsexual” remains strong in the medical community because of the prior use of the diagnosis “transsexualism” (later changed to “gender identity disorder”) in the Diagnostic and Statistical Manual of Mental Disorders. Clinicians should refrain from using the term “transsexual” unless and until they are sure that it is a term their patients are comfortable with.
u Sex: In a dichotomous scheme, the designation of a person at birth
as either male or female based on his or her anatomy (i.e., genitalia and reproductive organs) and biology (i.e., chromosomes and hormones). u Transgender: An umbrella term for people whose gender identity
u Transwoman: Generally refers to someone who was identified male
at birth but who identifies and portrays her gender as female. Alternate terms include “affirmed female,” “gender-affirmed female,” “MtF,” and “woman.”
and gender expression differs from their assigned sex at birth (i.e., the sex listed on the birth certificate). Use “transgender,” not “transgendered.”
FIGURE 2. Selected Transgender Terms and Definitions Note. Based on information from Fenway Health, 2010.
were comfortable with caring for MtF patients, and 29% (n = 41 of 141) were comfortable with caring for FtM patients. About 59% (n = 82 of 138) did not know the recommendations regarding breast
cancer screening for this population (Unger, 2015). Perrone et al. (2009) studied the effects of long-term testosterone on the endometrium of FtM patients and reported
TABLE 1. Effects of Hormones in FtM and MtF Transsexual People Effect
Onset (months)
Maximum (years)
Masculinizing Effects in FtM Transsexual People Receiving Testosterone Androgenic hair loss (scalp) Cessation of menses Clitoral enlargement Deepening of voice Facial hair Fat redistribution Increased muscle mass Skin oiliness and acne Vaginal atrophy
6–12 2–6 3–6 6–12 6–12 1–6 6–12 1–6 3–6
– – 1–2 1–2 4–5 2–5 2–5 1–2 1–2
Feminizing Effects in MtF Transsexual People Receiving Estrogen and Anti-Androgen Breast growth Decreased erections Decreased muscle mass and strength Decreased sperm production Decreased testicular volume Softening of skin Voice changes
3–6 1–3 3–6 – 3–6 3–6 –
2–3 3–6 1–2 >3 2–3 – –
FtM—female-to-male; MtF—male-to-female
Note. From “Endocrine Treatment of Transsexual Persons: An Endocrine Society Clinical Practice Guideline,” by W.C. Hembree, P. Cohen-Kettenis, H.A. Delemarre-van de Waal, L.J. Gooren, W.J. Meyer III, N.P. Spack, . . . V.M. Montori, 2009, Journal of Clinical Endocrinology and Metabolism, 94, p. 3145. Copyright 2009 by the Endocrine Society. Adapted with permission. 364
no evidence that testosterone increased or reduced the risk of cancer. However, atrophic effects of androgen on the endometrium and a possible risk of polycystic ovarian syndrome can occur (Perrone et al., 2009). Healthcare providers for patients with estrogen receptor–positive cancers may need to discuss contraindications for testosterone therapy because a portion of administered testosterone can be aromatized to estradiol. Providers must approach this topic in a sensitive manner, understanding that such discussion may be difficult for the patient. Urban, Teng, and Kapp (2011) reported a case of uterine cancer in one FtM patient and a case of cervical cancer in another FtM patient; both patients were on testosterone, and their malignancies were detected during gender reassignment surgery. Malignancies may go undetected when patients do not have regular, appropriate gynecologic care. Patients may also be uncomfortable continuing with oncology care associated with their birth gender (Urban et al., 2011). Hage, Dekker, Karim, Verheijen, and Bloemena (2000) reported two cases of ovarian cancer in FtM patients taking androgens, and they recommended simultaneous salpingo-oophorectomy in transgender men undergoing hysterectomy during gender-affirming therapy.
June 2015 • Volume 19, Number 3 • Clinical Journal of Oncology Nursing
In a review of the literature, Mueller and Gooren (2008) found that in a study following 2,200 MtF patients for more than 30 years, no breast cancer cases were reported. Estrogen alone appears to pose no increased risk of breast carcinomas and may be safer than estrogen plus progesterone therapy (Mueller & Gooren, 2008). In addition, one case of breast cancer was diagnosed in an FtM patient on testosterone therapy; the cancer was detected after chest surgery (Burcombe, Makris, Pittam, & Finer, 2003). Contradicting views exist of androgens as a risk factor or as protection against cancer development. Mueller and Gooren (2008) also observed that three cases of prostate cancer were diagnosed in MtF patients aged younger than 50 years taking estrogen; however, whether the cancer was estrogen sensitive or whether the malignancy was present prior to estrogen administration is unclear. Although the prostate becomes atrophic with androgen suppression, a cancer risk still exists. Unger (2014) recommended that MtF patients who have not had a vaginoplasty be evaluated by annual rectal examination after age 50 years. However, patients with a created
neovagina may require transvaginal palpation for adequate assessment (Unger, 2014). With prolonged estrogen exposure, prostate-specific antigen levels may be falsely low (Epstein, 1993). Brown and Jones (2015) examined the incidence of breast cancer among 5,135 transgender veterans on hormones. Ten cases of breast cancer were confirmed, including seven in FtM patients and two in MtF patients. The authors concluded that enough evidence did not exist to support a connection between crossgender hormones and breast cancer. However, Brown and Jones (2015) recommended that healthcare providers demonstrate more sensitivity and increase their knowledge about transgender care. For example, this population has many risk factors for breast cancer, including a transwoman’s long-term exposure to estrogen, testosterone converting to estradiol, and remaining breast tissue after a transman’s chest surgery (Unger, 2014). Evidence from long-term studies has concluded that malignancies related to hormone therapy are rare. Transitionrelated care is important to the health of many in the transgender population. Cancer rates related to decreased rates of
Screen transgender or transsexual people who have not used cross-sex hormones or had gender-affirming surgery using the same criteria and risk parameters as for people of their natal sex. Transmen (Past or Current Hormone Use) • Breast cancer: Perform an annual chest wall and axillary examination. Breast cancer screening using mammography should also take place as for natal females; it is not needed following chest reconstruction but should be considered if only a reduction was performed. • Cervical cancer: After total hysterectomy, if the individual has a prior history of high-grade cervical dysplasia or cervical cancer, do annual Papanicolaou (Pap) smear of vaginal cuff until three normal tests are documented, then continue to perform Pap smear every two to three years. • Cervical cancer if ovaries were removed, but uterus and cervix remain intact: Follow Pap smear guidelines for natal females, but deferring is an option if individual has no history of genital sexual activity. Inform pathologist of current or prior testosterone use; cervical atrophy can mimic dysplasia. • No hysterectomy: Follow published recommended guidelines for natal females (grade C). • Uterine cancer: Evaluate spontaneous vaginal bleeding in the absence of a mitigating factor (e.g., missed testosterone doses, excessive
screening in this population may be the result of discrimination; understanding the impact of fear on screening rates is an important research priority. Discussing reproductive health concerns should be a part of transgender health care, particularly when it relates to oncology care. Transgender populations have fertility concerns that are often unaddressed by providers. Transgender men may need to discuss cessation of testosterone if interested in becoming pregnant. Transgender women may need to use sperm banking services because of estrogen’s possible effect on sperm production (Wallace, Blough, & Kondapalli, 2014).
Implications for Practice and Conclusions Nurses play an important role in transgender health promotion and cancer screening. For example, nurses should ask patients how they identify their gender, name, and pronoun. Transgender affirmative language can help to increase screenings, particularly those that are related to gendered cancers. Assessment skills should include knowing how and
testosterone dosing leading to increased estrogen levels, weight changes, thyroid disorders) as for postmenopausal natal females. Consider hysterectomy if fertility is not an issue, patient is aged 40 years or older, and health will not be adversely affected by surgery. • Follow standard screening recommendations for other cancers. Transwomen (Past or Current Hormone Use) • Breast cancer: Perform breast cancer screening using mammography in patients aged 50 years or older with additional risk factors (e.g., estrogen and progestin use of more than five years, positive family history, body mass index of 35 or greater). • Prostate cancer: Prostate-specific antigen (PSA) is falsely low in an androgen-deficient setting, even in the presence of cancer; only consider PSA screening in high-risk patients. Use a digital rectal examination to evaluate the prostate in all transwomen (grade C). • Pap smears in neovaginas are not indicated; the neovagina is lined with keratinized epithelium and cannot be evaluated with a Pap smear. Perform periodic visual inspection with a speculum, looking for genital warts, erosions, and other lesions. If a sexually transmitted infection is suspected, do a culture swab, not polymerase chain reaction. Neovaginal walls are usually skin, not mucosa; when it is mucosa, it is urethral or colon mucosa. • Follow standard screening recommendations for other cancers.
FIGURE 3. Cancer Screening Guidelines for Transgender or Transsexual People Note. From “Primary Care Protocol for Transgender Patient Care,” by the Center of Excellence for Transgender Health, 2011. Retrieved from http://transhealth.ucsf.edu/trans?page=protocol-00-00. Copyright 2011 by the Center of Excellence for Transgender Health. Adapted with permission. Clinical Journal of Oncology Nursing • Volume 19, Number 3 • Oncology Essentials
365
Journal Articles American Journal of Nursing “Lesbian, Gay, Bisexual, and Transgender Health: Is Nursing Still in the Closet?” http://bit.ly/1GZKlFV
ship resources, end-of-life care, and referrals. Education is an essential foundation for nurses, particularly within the field of oncology, and it promotes the delivery of excellent transgender affirmative care.
Nursing Made Incredibly Easy “Caring for Transgender Patients” http://bit.ly/1IONxWZ
References
Online Resources Callen-Lorde Community Health Center Transgender Health Services http://bit.ly/1RdHj6o Gay and Lesbian Medical Association Healthy People 2010: A Companion Document for Lesbian, Gay, Bisexual, and Transgender (LGBT) Health http://bit.ly/1H1ADWa Joint Commission Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community http://bit.ly/1P0Zpdl World Professional Association for Transgender Health Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People http://bit.ly/1pwKKpd
FIGURE 4. Transgender Care Resources for Healthcare Providers why to ask about patients’ history of feminizing and masculinizing interventions. The language used during physical examinations should not be based on the gender patients were assigned at birth, but instead on how patients identify their body and gender. Assessment should be sensitive to degendering the treatment, appropriate clinical screening, and the language of cancer (e.g., avoiding terms like “women’s cancer” and “men’s cancer”). Body parts of all genders may be different because of cancer-related surgeries and treatment. A number of resources regarding the care of transgender people are available (see Figure 4). The oncology healthcare team, with oncology nurses as essential team members, can greatly improve the clinical care of members of the transgender population. Challenges for the transgender population include establishing care with supportive and sensitive providers, as well as gaining effective access to transgendersensitive cancer support groups, survivor366
Asscheman, H., Giltay, E.J., Megens, J.A., de Ronde, W.P., van Trotsenburg, M.A., & Gooren, L.J. (2011). A long-term follow-up study of mortality in transsexuals receiving treatment with cross-sex hormones. European Journal of Endocrinology, 164, 635–642. doi:10.1530/EJE-10-1038 Brown, G.R., & Jones, K.T. (2015). Incidence of breast cancer in a cohort of 5,135 transgender veterans. Breast Cancer Research and Treatment, 149, 191–198. doi:10.1007/s10549-014-3213-2 Burcombe, R.J., Makris, A., Pittam, M., & Finer, N. (2003). Breast cancer after bilateral subcutaneous mastectomy in a female-to-male trans-sexual. Breast, 12, 290–293. doi:10.1016/S0960 -9776(03)00033-X Clements-Nolle, K., Marx, R., & Katz, M. (2006). Attempted suicide among transgender persons: The influence of genderbased discrimination and victimization. Journal of Homosexuality, 51, 53–69. doi:10.1300/j082v51n03_04 Dean, L., Meyer, I.H., Robinson, K., Sell, R.L., Sember, R., Silenzio, V.M.B., . . . Xavier, J. (2000). Lesbian, gay, bisexual, and transgender health: Findings and concerns. Journal of the Gay and Lesbian Medical Association, 4, 101–151. Epstein, J.I. (1993). PSA and PAP as immunohistochemical markers in prostate cancer. Urologic Clinics of North America, 20, 757–770. Fenway Health. (2010). Glossary of gender and transgender terms. Retrieved from http://www.lgbthealtheducation .org/wp-content/uploads/Handout_7-C _Glossary_of_Gender_and_Transgender _Terms__fi.pdf Grant, J.M., Mottet, L.A., Tanis, J., Harrison, J., Herman, J.L., & Keisling, M. (2011). Injustice at every turn: A report of the National Transgender Discrimination Survey. Retrieved from http://www.the taskforce.org/static_html/downloads /reports/reports/ntds_full.pdf Hage, J.J., Dekker, J.J., Karim, R.B., Verheijen, R.H., & Bloemena, E. (2000). Ovarian cancer in female-to-male transsexuals: Report of two cases. Gynecologic Oncology, 76, 413–415. Hotton, A.L., Garofalo, R., Kuhns, L.M., &
Johnson, A.K. (2013). Substance use as a mediator of the relationship between life stress and sexual risk among young transgender women. AIDS Education and Prevention, 25, 62–71. doi:10.1521/ aeap.2013.25.1.62 Institute of Medicine. (2011). The health of lesbian, gay, bisexual, and transgender people: Building a foundation for better understanding. Washington, DC: National Academies Press. Lambda Legal. (2010). When health care isn’t caring: Lambda Legal’s survey on discrimination against LGBT people and people living with HIV. Retrieved from http://www.lambdalegal .org/sites/default/files/publications/ downloads/whcic-report_when-health -care-isnt-caring.pdf Lombardi, E. (2010). Transgender health: A review and guidance for future research—Proceedings from the Summer Institute at the Center for Research on Health and Sexual Orientation, University of Pittsburgh. International Journal of Transgenderism, 12, 211–229. doi:10 .1080/15532739.2010.544232 Mueller, A., & Gooren, L. (2008). Hormonerelated tumors in transsexuals receiving treatment with cross-sex hormones. European Journal of Endocrinology, 159, 197–202. doi:10.1530/EJE-08-0289 Nemoto, T., Bödeker, B., & Iwamoto, M. (2011). Social support, exposure to violence and transphobia, and correlates of depression among male-to-female transgender women with a history of sex work. American Journal of Public Health, 101, 1980–1988. doi:10.2105/AJPH.2010 .197285 Peitzmeier, S.M., Reisner, S.L., Harigopal, P., & Potter, J. (2014). Female-to-male patients have high prevalence of unsatisfactory Paps compared to non-transgender females: Implications for cervical cancer screening. Journal of General Internal Medicine, 29, 778–784. doi:10.1007/ s11606-013-2753-1 Perrone, A.M., Cerpolini, S., Maria Salfi, N.C., Ceccarelli, C., De Giorgi, L.B., Formelli, G., . . . Meriggiola, M.C. (2009). Effect of long-term testosterone administration on the endometrium of female-to-male (FtM) transsexuals. Journal of Sexual Medicine, 6, 193–200. doi:10.1111/j.1743-6109.2009.01380.x Sanchez, N.F., Sanchez, J.P., & Danoff, A. (2009). Health care utilization, barriers to care, and hormone usage among male-to-female transgender persons in New York City. American Journal of
June 2015 • Volume 19, Number 3 • Clinical Journal of Oncology Nursing
Public Health, 99, 713–719. doi:10.2105/ AJPH.2007.132035 Unger, C.A. (2014). Care of the transgender patient: The role of the gynecologist. American Journal of Obstetrics and Gynecology, 210, 16–26. doi:10.1016/j .ajog.2013.05.035 Unger, C.A. (2015). Care of the transgender patient: A survey of gynecologists’ current knowledge and practice. Journal of Women’s Health, 24, 114–118. doi:10.1089/jwh.2014.4918 Urban, R.R., Teng, N.N., & Kapp, D.S. (2011). Gynecologic malignancies in female-to-male transgender patients: The need of original gender surveillance. American Journal of Obstetrics and Gynecology, 204, e9–e12. doi:10.1016/j .ajog.2010.12.057 U.S. Department of Health and Human
Services. (2012). U.S. Department of Health and Hu man Ser vices recommended actions to improve the health and well-being of lesbian, gay, bisexual, and transgender communities. Retrieved from http://www.hhs.gov/lgbt/resources /reports/health-objectives-2011.html U.S. Department of Health and Human Services. (2015). Healthy People 2020: Lesbian, gay, bisexual, and transgender health. Retrieved from http://w w w.healthy
people.gov/2020/topicsobjectives2020/ overview.aspx?topicid=25 Vogel, L. (2014). Screening programs overlook transgender people. Canadian Medical Association Journal, 186, 823. doi:10.1503/cmaj.109-4839 Wallace, S.A., Blough, K.L., & Kondapalli, L.A. (2014). Fertility preservation in the transgender patient: Expanding oncofertility care beyond cancer. Gynecological Endocrinology. Advance online publication.
Do You Have an Interesting Topic to Share? Oncology Essentials provides readers with a brief summary of oncology nursing basics. Length should be no more than 1,000–1,500 words, exclusive of tables, figures, insets, and references. If interested, contact Associate Editor Erin Hartnett, DNP, APRN-BC, CPNP, at [email protected].
Clinical Journal of Oncology Nursing • Volume 19, Number 3 • Oncology Essentials
367
Copyright of Clinical Journal of Oncology Nursing is the property of Oncology Nursing Society and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
