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, is now used to highlight “the complexity of attending to the many biopsychosocial needs of transgender patients due to numerous barriers to care”, according to a study published in LGBT Health, a peer-reviewed journal from Mary Ann Liebert, Inc., publishers.
In “A Transgender Woman with Testicular Cancer: A New Twist on an Old Problem,” Carolyn Wolf-Gould, MD and Christopher Wolf-Gould, MD provide a detailed account of a 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.
According to Drs. Wolf-Gould, the delay in detection of the cancer may have been because:
- of 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.
As such, “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,” stated the authors.
For the authors, “over the last decade, gains for transgender people with regard to human rights and access to medical care have led to increasing numbers of patients seeking medical treatment for gender dysphoria. (But) the paucity of evidence-based treatment guidelines, lack of insurance coverage, and dearth of professional forums to review complex cases mean that providers are often uncertain about how best to assist their patients. In this case, testicular cancer was eventually identified because of rising testosterone and estradiol levels in a patient whose testosterone should have been suppressed by her hormonal therapy.”
The authors also recognized that “diagnosis of disease in body parts that are incongruent with a patient’s gender identity can make both patients and providers uncomfortable. Diagnosing testicular cancer in a woman or cervical cancer in a man is counterintuitive. While many transgender individuals are comfortable with their natal body parts, others experience intense anatomical dysphoria, which can result in discomfort with physical examinations or even reluctance to touch or acknowledge their own genitals.”
In this patient’s case, in particular, “the anatomical dysphoria contributed to a delay in diagnosis.”
The authors now recommend that:
- transgender healthcare can and should be provided as part of primary care; and
- attention to the care of other minority populations as part of traditional medical education and the skill set required for treatment of transgender patients be added to this curriculum.
“We have arrived at a ‘tipping point’ with regard to human rights for transgender citizens. It is our hope that the medical community will rise to the challenge of developing new medical systems to meet the needs of this population,” Drs. Wolf-Gould ended.
