Printed on: June 15th, 2025

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Cancer, sexuality and gender

Cancer, sexuality and gender

Sarah is a 50-year-old trans woman who has been taking oestrogen for five years. She still has a male gender marker on her notes. She has approached the breast screening team to ask to be put on recall for breast screening, but had been told that this isn’t possible because she is registered as male, and that she should contact her GP surgery to request screening.

How should we be managing this situation in primary care?

This article was created in June 2024. Red Whale would like to thank Dr Dunx Shrewsbury for their expert advice reviewing this article.

This article discusses some of the specific challenges that LGBTQIA+ people may face in timely identification of cancer, appropriate access to healthcare and ongoing support after a cancer diagnosis.

We use some standard terms to describe sexuality and gender identity, drawn from the Standards of Care for the Health of Transgender and Gender Diverse People (Version 8) (International Journal of Transgender Health, 23(1),S1), the NHS inclusive language guide: Sex, gender and sexuality and Stonewall’s list of LGBTQ+ terms and definitions. We’ve included some very basic definitions here, recognising that we all come to this topic with different levels of experience and understanding.

Some LGBTQ+ people may have different risk factors for cancer compared with the rest of the population.

In July 2021, NHS Digital published data from a representative sampling of adults aged ≥16y who participated in the Health Survey for England between 2011 and 2018 (NHS Digital – Health and health-related behaviours of lesbian, gay and bisexual adults).

Around 2% of the surveyed population identified as lesbian, gay or bisexual, and their specific health issues were reported on for the first time.

Two key themes which may impact on the types of cancer, prevalence of cancer, uptake of screening and health-seeking behaviours of these adults were identified:

• Higher levels of harmful or potentially harmful alcohol intake, and current smoking (but lower levels of obesity).
• Poorer mental health and higher levels of mental, behavioural or neurodevelopmental disorders.

A BJGP study compared the prevalence of cancer risk factors in trans and cisgender people, using the UK CPRD (Clinical Practice Research Datalink) (BJGP 2023;73(732):e486). The study showed that in comparison with cisgendered people:

• Trans men had higher prevalence of obesity and ‘ever smoking’.
• Trans women had higher prevalence of dyslipidaemia, diabetes, hepatitis C and B, and HIV.

LGBTQIA+ people are at higher risk of ‘minority stress’ – a chronic and underlying fear about discrimination and prejudice that arises from stigmatised social or gender identity (Psychol Bull. 2003; 129(5):674). This is exacerbated by health systems being ‘heteronormative’ (meaning that they are set up primarily to meet the needs of straight and cisgender people).

The consequences of this are: 

• Under-reporting of risk factors for cancer, e.g. smoking, alcohol intake, due to anticipating judgement from health professionals.
• Reluctance to present with cancer symptoms because of negative personal experiences with health services, or experiences reported by others.
• Cancer awareness campaigns may be less effective at reaching LGBTQIA+ people due to the way they are targeted. This can result in a lack of awareness of cancer warning signs/symptoms, and confusion as to whether positive health interventions (such as vaccination against HPV or screening) are relevant for them.

Advice taken from the GMC ethical hub – trans healthcare, the BMA – managing patients with gender dysphoria, and Transactual – supporting trans patients: a quick guide for GPs, alongside other references where noted.

Gender identity can be fluid over time or circumstance. In most definitions, the term ‘trans’ refers to people whose gender identity does not align with their birth-assigned sex, and includes transgender men and women, non-binary people and gender-fluid/gender-queer people.

The NHS guidance on inclusive content defines transgender like this:

“We use ‘trans’ as an umbrella term to describe people whose current gender identity or way of expressing their gender differs from the sex they were registered with at birth. Some, but not all, trans people want to transition (change) socially or medically or both”.

Practically, this means that trans people may:

• Have socially transitioned, which may involve changing their name and appearance.
• Have undergone gender-affirming surgery.
• Be on gender-affirming hormone therapy (GAHT), with or without intention to have surgery.
• Not be on GAHT or had gender-affirming surgery.

As well as experiencing the same challenges in cancer care as our other LGTBQIA+ patients, there are some issues that affect trans people in particular; these relate to gender-affirming treatment with hormones or surgery, and difficulty accessing cancer screening programmes. In this section, we explore some of these issues in more detail.

With very long waits to see NHS gender services, gender-affirming hormone treatments may be obtained from a variety of sources, including private providers, unregulated organisations or even friends. It is important that if we are aware someone is sourcing GAHT, we maintain an honest, non-judgemental approach to this.

For quick reference, the known risks and some cancer-related implications of gender transition are summarised in the table below (International Journal of Transgender Health 2022;23:S1, Trends in Cancer 2022;8:273). This table is intended to guide our discussions with patients about potential implications of GAHT on cancer risk, but we need to be aware that research on the long-term impact of GAHT on cancer risk is still limited, and some data can be of variable quality. Some of the risks summarised here are more theoretical than others, and will depend on individual factors as well as doses and treatment duration.

Patients will only be invited for cancer screening according to their registered gender, which may result in missed screening or invitations for inappropriate screening (gov.uk – NHS population screening: information for trans and non-binary people).

In primary care, we will need to be alert to this, and support our patients to access the screening they need. Two codes are provided to help in searching for these groups: the ‘Gender Identity’ code and the ‘Gender Same at Birth’ indicator code (NHS Digital – gender identity, accessed May 2024). (Colleagues at the Sussex Gender Service have told us they recommend that practices consider developing an in-house, transient (so only active while necessary for good patient care) database to support them in recall for these patients.)

• If you are sending a smear sample for a person registered as male, it is vital to inform the laboratory that the patient does have a cervix because the sample may otherwise be rejected.
• OUTpatients has some excellent resources for trans men and non-binary people to support them to attend cervical screening; see the useful resources section at the end of this article.
• In some cities, including London, Brighton and Glasgow, specialist clinics have been set up, usually as part of sexual health services. People can arrange to attend these services even if they do not live in those areas (links below).
• Those taking testosterone may experience vaginal atrophy, and this can increase discomfort. (Personal communication from colleagues working in this area suggests that using topical vaginal oestrogen for 2–4 weeks prior to cervical screening can be helpful and, as we know from use in other patient populations, is not systemically absorbed (i.e. it is safe for transgender men and non-binary people to use without feminising effects.)

• It is important to remember that gender-diverse people may prefer the terminology ‘chest’ to ‘breasts’ – we should ask and/or follow the person’s lead.
• Trans women treated with oestrogens will be at higher risk of breast cancer than cisgender men (gov.uk – NHS population screening: information for trans and non-binary people).
• Trans men who have any breast tissue should be invited for mammography, but will not be routinely invited by the national screening programme if now registered as male with their GP.
  • Trans men who have not had top surgery (mastectomy and sculpting of the chest wall) should be referred by their GP practice to the breast screening service, with their agreement. They can directly contact the service to request appropriate appointment scheduling and awareness on the part of the screening team, to avoid unnecessary distress and embarrassment.
  • If mammography screening is not possible, the patient should be advised to continue self-checking (gov.uk – NHS population screening: information for trans and non-binary people).
  • For those who have had ‘top surgery’, the need to continue with breast screening will depend on the volume of breast tissue left, and this should have been specifically discussed with them by their surgeon – we can document this in the medical record.

The risk of prostate cancer is the same for trans women as cis men if:

• They are not on gender-affirming hormone therapy.
• They have not had gender-affirming surgery (e.g. orchidectomy).

The risk in trans women who have started GAHT or had gender-affirming surgery is a little less than age-matched cis male controls, BUT it may be more tricky to spot (BJU Int 2022;129:113).

Here are some tips (BJU Int 2022;129:113) :

• We shouldn’t forget the possibility of a prostate malignancy. Consider in those with urinary symptoms that could be misattributed as UTIs.
• Digital rectal prostate examination may not be possible: in gender-reassignment surgery, the prostate gland is not removed due to risk of damage to adjacent structures. If a vaginoplasty has been performed, the prostate can only be palpated via the anterior neovaginal wall, so identifying malignancy on examination may not be possible in primary care.
• Ensure the PSA test laboratory form states that the person was AMAB: some laboratories will refuse to process a PSA blood test for a patient registered as female.
• Advise to avoid receptive anal sex for 1 week prior to a PSA test to avoid false positives (BJU Int 2022;129:113). (Although there is no formal guidance in this area, personal communication from colleagues working in this area tells us it is advisable to avoid neovaginal penetrative intercourse for the same period due to the position of the prostate post vaginoplasty.)
• Expert consensus is that the upper limit of a ‘normal PSA’ for this group should be set at 1ng/ml. We may need to seek advice and guidance or speak to colleagues in secondary care to help people navigate the suspected cancer pathway in this situation – where a PSA may be >1ng/ml, but not reach official referral criteria (BJU Int 2022;129:113). We also need to be careful that we don’t unwittingly file a PSA flagged by the lab as ‘normal’ when it is in fact abnormal for our trans patient. Might this be a useful action point to share with your colleagues?

A report by Macmillan highlighted some of the huge issues that LGBTQIA+ patients can come across in accessing healthcare that is appropriate for them and their individual needs (Macmillan - The Emerging Picture: LGBT people with cancer and later report, Macmillan - No One Overlooked).

Respondents reported being less likely to feel that they had been told about their diagnosis sensitively, and less likely to believe they were treated with dignity and respect by staff. There were reported episodes of misgendering; unintentional ‘outing’ of patients to friends and family; partners being mistitled as ‘friend’ or even ‘siblings’ rather than a recognition of their relationship with the patient; and a lack of understanding of the differing role that biological vs. chosen family may play in someone’s support network.

2021 NHS Digital data on the health of lesbian, gay and bisexual patients showed that LGB people have lower average emotional wellbeing scores, and are more at risk of having a behavioural or neurodevelopmental disorder, than straight people, which may impact them as they come to terms with a cancer diagnosis (NHS Digital - Health Survey England Additional Analyses: health and health-related behaviours of lesbian, gay and bisexual adults). For a look at the link between gender and neurodiversity, see our article Neurodivergence: an umbrella approach.

Many cancer patients struggle with the psychosexual impacts of cancer diagnosis and treatment. Their body image, energy levels and libido are commonly affected. They may blame themselves for their cancer, or struggle with returning to normal life because of the cancer and its treatment.

For LGBTQIA+ people, these issues can be compounded by other difficulties, for example internalised stigma and beliefs that their sexuality has in some way caused their disease; a potential lack of family support; and the potential impact of this diagnosis on plans around GAHT or gender-affirming surgery.

Patients may not mention difficulties with sex due to embarrassment, a fear of being judged or just because it isn't seen as ‘medical’. As clinicians, we may also be less sure what services and support we can access for patients with sexual or sexual intimacy issues. For LGBTQIA+ people, this can mean that someone's gender identity or sexuality is ignored or not appreciated before, during and after treatment, and the advice they are given may be skewed towards the heteronormative.

One example of where cancer treatment can impact on LGBTQIA+ people is the treatment of prostate cancer (Syst Rev 2021;10:183):

• In prostate cancer, radiotherapy treatment requires abstention from receptive anal sex for 8 weeks. It is important that this is discussed with men who have sex with men as part of the information they are given pre-treatment because it may significantly impact on patients’ relationships and mental health.
• For men who have sex with men, erectile dysfunction post-cancer treatment may mean that they need to use additional measures to obtain an erection such as medication, injections or a pump. This all needs pre-planning, and this may impact on sex and sexual intimacy.
• Anal sex requires a firm erection, and standard treatments for erectile dysfunction may not be fully effective. These patients may benefit from early input from andrology or specialist centres.
• After treatment for prostate cancer, men may develop retrograde ejaculation, which may be psychologically important to our patients.

There are far fewer studies around trans patients and cancer, including very little on the effect of radiotherapy treatment on the neovagina in trans women.

One example of where sexuality can impact body identity is breast reconstruction after breast cancer treatment. There is some evidence from a systematic review, and from Macmillan-funded survey data, that gay and bisexual women report feeling pushed towards considering breast reconstruction by their medical teams, whereas they expressed feeling less focused on the appearance of the breast and more focused on breast sensation and sensitivity (https://systematicreviewsjournal.biomedcentral.com/articles/10.1186/s13643-021-01707-4, Lesbian, Gay, Bisexual and Queer Experiences of Cancer Care).

Trans patients may be advised to stop using, or to delay starting, gender-affirming hormone or surgical treatments during diagnosis and active treatment. This can cause significant distress, and some patients may refuse to accept treatments that could impair their transition.

Many issues and concerns raised by LGBTQIA+ patients will be no different to those raised by any individual in this situation: the psychological impact of the diagnosis; the effects of treatment; the concerns about loved ones and the future; and the impact on work, finances and body image. Maintaining open and empathetic, individualised care is key:

• Treat all patients with respect and kindness.
• Ask questions about sexuality and gender, and, if appropriate, record the information in the clinical notes to reduce duplication.
• Explore the patient’s concerns and ideas in a safe and supportive environment.
• Contextualise: what issues do they envisage, and what can you see as potentially being an issue(s), knowing what cancer and treatment they may have had.
• Signpost:
  • Investigate the local services that you have access to.
  • The UK Cancer and Transition Service will accept self-referral from patients across the UK with cancer or a history of cancer where they feel it impacts on their gender-affirming care.
  • We have included below some resources that offer a wide perspective on different cancers and their impacts on different members of the LGBTQIA+ community. CRUK, Macmillan and Prostate UK have excellent sections on their websites looking at screening, diagnosis, treatment and life after cancer. OUTpatients, a cancer charity designed for LGBTQIA+ people, has a number of excellent resources for patients and professionals.

	Cancer, sexuality and gender Sexuality and gender identity can potentially impact on all stages of someone's cancer journey. LGBTQIA+ people have higher rates of some cancer risk factors, such as smoking and alcohol consumption, and report experiencing discrimination in accessing cancer care. Trans people may need our help to ensure they are accessing appropriate screening programmes. Gender-affirming treatments can affect presentations and testing for some cancers.
	How do you ensure that your practice is as welcoming as possible for LGBTQIA+ patients? How could you make sure that sexuality and/or gender identity is accurately coded?
	Useful resources: Websites (all resources are hyperlinked for ease of use in Red Whale Knowledge) Resources on cancer screening: gov.uk - NHS population screening: information for trans and non-binary people RM Partners - no barriers cervical screening for trans and non-binary people OUTpatients - trans clinics offering cervical screening OUTpatients - cancer risk and screening gov.uk – PHE screening blog: reducing cervical screening inequalities for trans people Resources on living with cancer: The UK Cancer and Transition Service Prostate Cancer UK – information for gay and bisexual men The Eve Appeal (information for trans, non-binary and intersex communities regarding gynaecological cancer) Lesbian, Gay, Bisexual and Queer Experiences of Cancer Care (impact of breast cancer treatment and breast sensation, or loss of breasts) OUTpatients – provider pack CRUK – improving cancer care for the LGBTQIA+ community