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Health-care disparities contribute to delayed testicular cancer diagnosis in a transgender woman

A family physician reports the case of a transgender woman whose testosterone levels rose unexpectedly while on feminizing hormones, leading eventually to a diagnosis of a rare, virilizing form of testicular cancer. The complex medical and psychosocial factors related to the care of transgender patients that contributed to the delay in diagnosis are examined in the study published in LGBT Health, a peer-reviewed journal from Mary Ann Liebert, Inc., publishers. The article is part of a new Special Issue on LGBT Populations and Cancer and is available free to download on the LGBT Health website.

In “A Transgender Woman with Testicular Cancer: A New Twist on an Old Problem,” Carolyn Wolf-Gould, MD and Christopher Wolf-Gould, MD, A.O. Fox Memorial Hospital, Oneonta, NY, provide a detailed account of the 28-year-old transgender woman’s care, beginning when she requested feminizing hormone therapy from a family physician who was relatively new to the care of transgender patients. Despite initiation of appropriate testosterone-blocking and feminizing hormone therapy, and no evidence of a testicular mass at the initiation of treatment and 13-month follow-up, the patient’s testosterone levels began to rise and continued to do so. She denied the presence of a testicular mass; however, a cancerous mass was discovered on examination at her 24-month visit.

Drs. Wolf-Gould detail the factors that contributed to the delay in detection of the cancer. These included a failed attempt to access insurance coverage for vaginoplasty and the patient’s emotional response to this setback, transportation and distance challenges that caused her to miss appointments, and anatomical dysphoria– the patient’s reluctance to examine her testes despite awareness of change within her scrotum. This case underscores the need to remove barriers to care for transgender patients, develop better evidence-based treatment guidelines, and create venues for medical providers to learn appropriate biopsychosocial care for this underserved population. The authors discuss screening recommendations for patients whose anatomy does not match their gender identity.

“This case illustrates the complexity of attending to the biopsychosocial needs of transgender patients due to numerous barriers to care including the scarcity of resources for case consultations and provider education,” says LGBT Health Editor-in-Chief William Byne, MD, PhD, James J Peters VA Medical Center, Bronx, NY, and Icahn School of Medicine at Mount Sinai, New York, NY.