Nearly 1.6% of adults in the United States identify as transgender, nonbinary, or gender nonconforming.1 Although these populations are growing, especially among younger generations — 5% of young adults report they do not identify with the sex assigned to them at birth1 — they remain increasingly affected by cancer screening disparities. Eligible transgender patients at one hospital were 70% less likely than cisgender patients to be screened for breast cancer, 60% less likely to be screened for cervical cancer, and 50% less likely to be screened for colorectal cancer.2
These low numbers are due to many factors, including physician bias, lack of education regarding risk factors, and the failure of many insurance plans to cover the cost of gender-affirming care and mental health resources.2 “A significant number of these patients report postponing medical care because of previously experienced discrimination,” says Stamatia V. Destounis, MD, FACR, chair of the ACR Commission on Breast Imaging.
“There’s a large body of evidence showing transgender and gender-nonconforming people have a life filled with systemic discrimination — first fired, last hired. We’re also more likely to be in the lowest socioeconomic classes and lack proper supports,” explains Scout, MA, PhD, executive director of the National LGBT Cancer Network. “Whenever these patients need to find a new provider, they’re not sure it will be a safe space, so they’re risking exposing themselves to new trauma on top of what they already face. It’s pretty easy to imagine how they may not feel up to that burden and put it off.”
UNDERSTAND THE ISSUE
One reason transgender patients may not feel welcome in an imaging suite may be a lack of understanding on the physician’s part, according to a recently published JACR® article. Although a
majority of surveyed breast radiologists felt comfortable speaking to their patients regarding sex or gender identity in the context of cancer screening, nearly 70% were either unsure or had no
LGBTQ competency training for staff or physicians.3 Only a third of respondents stated they followed breast cancer screening guidelines for transgender women using hormone treatment, and
most respondents did not provide or were unsure of screening recommendations regarding transgender men who had not undergone chest contouring or breast removal surgery (these individuals should follow the same screening recommendations as cisgender women).3 “Although diagnostic imaging protocols for transgender patients can be similar to those of cisgender patients, screening guidelines can be much more variable depending on risk status, hormonal treatment, or surgical treatment. We need a clear understanding of the guidelines ourselves to diagnose and treat patients appropriately and to provide educational outreach to these populations,” says Destounis, also one of the authors of the paper.
Lack of proper knowledge can also lead to everyday verbal, nonverbal, and environmental slights, snubs, or insults that communicate hostile, derogatory, or negative messages. This can be both intentional and unintentional. “Not understanding how we might have extra barriers can lead to some really challenging discussions. It’s enough to knock us completely off course,” says Scout. Many resources exist to help radiologists and radiology staff understand the needs particular to this patient population. The College has published its ACR Appropriateness Criteria® for breast imaging of transgender patients. The National LGBT Cancer Network has released a training series called “Welcoming Spaces,” which is aimed at all levels of staff and covers topics such as barriers to care and proper terminology.
Not understanding how we might have extra barriers can lead to some really challenging discussions. It's enough to knock us completely off course.
MAKE YOUR PRACTICE WELCOMING
Beyond seeking education, one of the first and easiest ways to improve imaging for transgender individuals is to determine whether your practice or department is welcoming for LGBTQ people overall, says Scout. “Physicians need to demonstrate visually that their spaces are LGBTQ-friendly, then follow up with real attempts to make that space welcoming,” he adds. This starts with visual cues, such as rainbow flags or signs indicating your practice is a safe space. Radiologists should also look at their practice or department websites to ensure visual cues are in place. “That’s where a lot of patients will go first to see if you’re the right place for them,” says Scout. Scout advises to ensure the language and images on the website and in signage and brochures is gender neutral. “A transgender man isn’t going to look at a pink mammography van or see a sign for women’s health and think that’s for him,” Scout says.
Destounis also urges radiologists to look beyond the waiting room for ways to actively signal acceptance. “Find ways to make your practice more inclusive such as providing gender-neutral bathrooms or gowns — ones that aren’t pink,” she says. Both Destounis and Scout encourage posting non-discrimination signs or other policies that relate directly to gender identity.
USE INCLUSIVE LANGUAGE
The language used around imaging, particularly ones that are commonly associated with a specific gender like breast imaging, can also make a world of difference to transgender and gender-nonconforming patients. Scout notes that many clinical guidelines that would be experienced by nearly all assigned female at birth are often only directed at and mention cisgender women. Not only is the language not inclusive, but not including others can also cause confusion for the patient.
Other inclusive language involves using proper terminology and preferred pronouns. “One easy way to educate the world around you is to put pronouns next to your name. Adding your own preferred pronouns doesn’t necessarily mean you’re queer, but it does signal that you understand there’s a disparity here and are normalizing the practice. It’s a powerful way to say you’re trying to be part of the solution and that if a patient would like to share their preferred pronouns, the floor is open,” explains Scout. From there, radiologists can also add the option of including those pronouns in the patient’s record to ensure they are used by all staff, adds Destounis.
MAKE A DIFFERENCE
Although actions such as putting up flags and safe space signs may seem small, they make a huge difference to the entire LGBTQ community and can help stop the growing screening disparity.
“Radiologists need to help patients understand they’re coming to a space that is more welcoming than the general world right now,” says Scout. “Every effort counts.”