October is Breast Cancer Awareness month, a time when many are reminded of the life-saving potential of annual mammogram screenings. But for members of the LGBTQIA+ community, particularly those who are transgender, the topic of breast health can be challenging. By popular convention, most breast cancer awareness efforts are focused primarily on cisgender women. This, coupled with a general scarcity of information on transgender health, leaves many trans women, trans men and non-binary people in the dark when it comes to the importance of monitoring breast health. To help us explore this issue and offer guidance for both patients and providers, we spoke with Dr. Maria Benjamin, breast surgical oncologist at Northwest Hospital.
Dr. Benjamin's work as a breast surgeon gives her a unique perspective on both the needs of patients and the existing practices of providers. She explains that conversations about inclusive breast care are important in helping to "make sure that our community feels safe and included," raising the example of patient intake forms, such as those used to help assess patients' risk of breast cancer. "Our language is important for respectfulness, but our language is also important because it changes how patients understand us and the information we receive and the risk estimates that we give to people."
When it comes to breast screening recommendations for transgender people, Dr. Benjamin explains that information is regrettably sparse, but nonetheless provides insight on some of the few guidelines which are presently available. For example, the University of California, San Francisco, recommends that trans women should begin screening mammograms at age 50 if they have been using estrogen hormone replacement therapy (HRT) for a minimum of five years. The American College of Radiology, however, issues guidance that for average-risk trans women with hormone use greater than five years, it may be appropriate to start screening mammograms at age 40. These differences emphasize the importance of discussing risk factors with providers and underscore the importance of gender-inclusive approaches care.
Like trans women, transgender men also face challenges in seeking guidelines for breast cancer prevention, and trans men are additionally subject to messaging almost entirely crafted for and directed at those who identify as women. Though most recommendations can be assumed to be the same for trans men as they are for cis women, a more inclusive approach to communicating these recommendations stands not only to benefit trans men, but also women.
"Being compassionate towards our trans men patients also benefits cis women as well...The most important thing is the person that you are treating and making sure that you understand the person's goals, and our goal is to save the life of the individual." Historically, many popular efforts to promote breast cancer awareness have reduced breast cancer patients to the affected body part or parts, rather than focusing on the human being whose life is at risk. For providers treating patients of any gender identity, says Dr. Benjamin, "understanding patients' goals for themselves is important. I ask patients about what their goals for their own bodies, and that can help drive our conversations about what they want to do for their surgical management."
While systemic change is required to fully address trans-exclusionary messaging and practices, Dr. Benjamin offers advice which can help improve experiences in a very immediate sense. She encourages patients to express concerns about lack of information to their providers directly. "I think it's reasonable as a patient to say 'I'm not sure what the recommendations are or what the data is for me to make sure that I'm taking care of my health and all of my health screening needs moving forward. Do you know what any of the recommendations are for patients like me?'" She adds that even though doctors may not be immediately sure of the answer, the question compels them to seek out this information, broadening their own knowledge in the process. And to providers, Dr. Benjamin gives the following advice: "We need to make sure that our staff is educated, that we offer an opportunity for patients to tell us their preferred name, and that we use their preferred name, and that our forms are representative of our values. But mostly, I think the biggest impact for patients is in staff education, making sure that staff is understanding and inclusive."
These are changes that providers have the power to enact in their own offices and practices, and which can make an immediate impact on the quality of care given not only to trans patients, but to all patients. For providers, a change as simple as starting to wear a pin with their pronouns, as Dr. Benjamin does, is a small gesture that can make a huge difference. "Being inclusive has very wide benefits to everybody, not just LGBTQ patients. It makes patients in general feel safe and included."
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