Cancer. WSW are 10 times more likely to not have received timely Pap tests and 10 times more likely to not have received timely mammograms compared with WSM, even after accounting for measures of healthcare access, sexual identity, and other potentially confounding factors.112

Findings from the National Health Interview Survey revealed that women in same-sex relationships experience greater odds of breast cancer mortality compared with married women. According to Cochran and Mays,103 nulliparity, more common in WSW, is a likely reason for increased risk of breast cancer.


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Approximately 70% of women aged more than 18 years reported having a pap smear within the past 3 years.113This is in contrast to the available data for WSW. The majority of surveys report that only 44% to 56% of WSW have regular Pap smears to screen for cervical cancer.73-76,114


Cervical smear showing cervical dysplasia.

Despite the efficacy of the Pap test, WSW continue to be at elevated risk of cervical cancer as a result of underuse of screening services and lack of knowledge about risk factors for cervical cancer and appropriate methods of prevention.115 Studies of WSW indicate that negative experiences with the healthcare system and misinformation about disease risk contribute to underuse of medical services in general73,116,117 and routine cervical cancer screening in particular.74,118 A study by Price and coworkers showed that lesbians have a misperception that they are less susceptible to cervical cancer than heterosexual women.119

Additional barriers to participation in routine cervical cancer screening may include lack of healthcare providers’ knowledge of disease risk in this population, providers’ failure to obtain a complete sexual history from WSW, and lack of willingness of WSW to disclose sexual orientation to care providers.67,73,120

Smoking is more common among sexual minorities, both men and women, than among their heterosexual counterparts.121-123 Also, women in this population are more likely than heterosexual women to drink alcohol123-125 and to be overweight or obese.101,124,126

Health issues among transgender individuals

A transgender individual is someone who expresses themselves as a sex different from that assigned at birth. A transsexual individual is someone who has undergone a permanent, surgical sex change. A transman is an individual born female who has undergone hormonal and/or surgical treatment for sex reassignment as a male (FtM). A transwoman is an individual born male who has undergone hormonal and/or surgical treatment for sex reassignment as a female (MtF). It is important to note that prior to sex reassignment surgery, an individual must live as a member of the opposite sex for a certain period of time.10,15,64

The prevalence of adult transgenderism and transsexualism is difficult to estimate. A commonly quoted estimate puts the US adult transgender population at about 700,000, or 0.3% of the population.127

Hormonal treatment. Transitioning can include hormone therapy, psychologic therapy, and surgery. Transgender patients can have extreme discomfort with their bodies, and they may find some elements of a physical examination traumatic. It is recommended that provider/patient trust be established before examining sensitive areas (eg, genital, rectal, and vaginal), unless there is an immediate, urgent need to proceed.128,129

The aim of hormonal treatment is to stimulate the development of the secondary sex characteristics of the new sex and to diminish those of the natal sex.130,131 The clinician must provide care for the anatomy that is present, but also recognize that there will be some health needs due to the remaining anatomic features from birth.131 For example, although a transgender MtF patient may have had gender-confirming surgery, she may still need to have prostate-specific antigen levels checked as she ages.

MtF transsexuals. For MtF transition, androgenic hormones need to be counteracted by estrogen. Estrogen hormone therapy is prescribed to induce breast formation, atrophy of the testicles, and female distribution of fat, and reduce male-pattern hair growth. The primary care clinician needs to ask about the details of the sexual reassignment surgery in order to consider the anatomy of the patient. For example, the patient should be asked if orchiectomy had been performed. If not, testicular cancer may be a risk.131

The prostate gland is usually left in place and can develop benign hyperplasia or cancer. The enlarged breast tissue can develop cancer and mammography is necessary. If the patient has the BRCA1 or BRCA2 gene mutation, which increases risk of breast cancer, prophylactic mastectomy may be advised. In surgical shortening of the urethra, stenosis of the neomeatus can occur.132 Vaginoplasty usually involves sigmoid colon epithelium; however, no reports of cancer in neovaginal tissue have been reported.133

Hormonal treatment with ethinyl estradiol, although efficacious, should be avoided. When taken at the dosages required for sex reassignment, there is increased risk of deep venous thrombosis and death from cardiovascular causes as compared with 17ß-estradiol. Smoking should be discouraged as this increases risk of thrombus formation in estrogen therapy.10,134-136

Studies assessing the metabolic effects of androgen deprivation and estrogen therapy in MtF transsexuals have shown that increases in visceral fat are associated with increases in triglyceride levels, insulin resistance, and blood pressure.137,138 Also, estrogen treatment can cause metabolic syndrome.137-140 Therefore, lipid and serum glucose levels should be periodically checked.