When transgender patients enter the exam room of Ada Stewart, M.D., a colonel in the U.S. Army Reserve, she tries to create an atmosphere where they feel comfortable answering sensitive questions.

Questions like, “Do you still have breasts? Do you still have a vagina? Do you still have a penis and testicles?” 

A certain level of comfort helps patients open up about those types of questions, as well as about their transition road maps and their health concerns — information that’s needed in order to provide accurate and necessary healthcare, Stewart said. The problem, she added, is that many providers don’t reach that level of comfort with their transgender patients because of their gaps in knowledge or implicit biases.

“You have to trust the provider to be able to open up and let them know your concerns and to have those conversations,” Stewart said. “The biggest thing I try to ensure is that patients know that I understand what they’re going through and that I’m there for them. That’s essential to making sure they have a safe place to go and get care.”

Cancer deaths have decreased in the past 50 years, thanks in large part to the widespread adoption of screening protocols. However, those protocols are based on studies that don’t include transgender people, and there are very few recommendations for that population specifically, according to a 2020 review of screening guidelines. 

Added to that, under the current guidelines, transgender people aren’t screened as often as their cisgender (people whose gender assigned at birth matches their identity) peers, multiple studies show.

During a study at a Canadian hospital in 2019, researchers found that transgender patients at the facility were less likely to receive recommended breast, cervical and colorectal cancer screenings compared to the cisgender population. The study also found that some doctors had not recommended appropriate screenings for patients whose gender had changed.

Researchers discovered instances when transgender men were uncomfortable undergoing a Pap test, during which cells are collected from the cervix. Stewart said that particular situation can be difficult to navigate. She starts by explaining the risks of cervical cancer and describing the procedure. 

“If they don’t feel comfortable, I tell them we can wait until they’re ready,” Stewart said. “Not forcing them through the exam and just being there for them and meeting them where they are is crucial.” 

Also in 2019, the American Cancer Society declared there was a “cancer screening crisis” for transgender people. The organization cited providers’ discrimination and ignorance, as well as patient discomfort and highly gendered healthcare systems as the causes. 

Stewart said there are many missed opportunities for cancer screenings among transgender people. 

“Many times, when they go to see healthcare professionals, there’s a stigma and discrimination and they’re treated poorly,” Stewart said. “You have to go into a clinic to be screened for various cancers, and they won’t go in for fear of how they’re going to be treated.” 

The discrepancy in screenings between transgender and cisgender people is also seen among U.S. veterans. 

According to the Transgender American Veterans Association, there are more than 163,000 transgender veterans in the country, and the VA is one of the largest providers of care to transgender people in the U.S. Yet one study found that the VA is providing sex-related cancer screenings at substantially lower rates to transgender veterans compared to their cisgender counterparts. 

Researchers attributed the discrepancy to the VA’s electronic health record (EHR) system, which allowed providers to change a patient’s sex at birth to their gender identity, but didn’t document the change. 

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In a fact sheet released by the VA in 2022, the department said that veterans have the right to change the “birth sex” entry in their medical record, but the VA cautioned against it. Current medical guidance recommends keeping that entry consistent with what’s on patients’ birth certificates, the VA fact sheet states. The document advises patients to talk with their doctors about the consequences of changing it. 

“It is the veteran’s right to have their birth sex listed in a way that affirms their gender identity,” the fact sheet states. “However, it is also important that veterans make this decision with a full understanding of the health and safety impact of this choice.”

The VA said that its electronic health record system now includes gender identity as a separate field.

Any discrepancies in healthcare among transgender people currently serving in the military are unclear. 

As of January 25, 2021, transgender people were allowed to openly serve in the military. There’s no official count of how many transgender troops are serving currently, but since the ban was lifted, military doctors have received training about caring for those individuals, Stewart said. 

While Stewart is seeing improvement, many providers still have a lot to learn about how to care for transgender service members, she said. 

“Within the military, we’re seeing more transgender individuals since the policy was put out that the military wouldn’t discriminate based on gender,” Stewart said. “I can say that the military is trying to do better, but there is still a huge gap in knowledge.”

This educational resource was created with support from AstraZeneca.