Health Concerns for the Transgendered

by the Ingersoll Gender Centre- Article appeared in Polare magazine: October 2003

The male-to-female transsexual or transgendered person wants them and, generally speaking, the female-to-male wants to get rid of them.

... there are not enough long-term studies of breast disease in the M.T.F. population to dismiss the possibility of increased risk (of breast disease)

Why this information? The male-to-female transsexual or transgendered person wants them and, generally speaking, the female-to-male wants to get rid of them. Breasts can be a source of pride to the M.T.F. as hormones work their alchemy. They can also be a source of anxiety if they don't develop as rapidly or as much as the M.T.F. feels they should. Breasts can also be just one more visible sign of the incongruity between the inner-self and the outward body presentation of the female-to-male transsexual or transgendered person.

This information is for both the F.T.M. and M.T.F. community. It will discuss the issue of breast care from two points of view: for the F.T.M.who is on androgen therapy and may or may not plan to have a mastectomy, and for the M.T.F. who is on a female hormone regimen and hopes to increase breast size.

Female-to-male transsexuals or transgendered People

It was estimated in the United States in 1996 that 184,300 genetic women would be diagnosed with breast cancer, and that 44,300, or 24 percent would die as a result. In fact, breast cancer is the leading cause of death, from all causes, for genetic women between the ages of thirty-five and fifty-four.

For the female-to-Male transsexual struggling with the body given to them at birth, breasts can at times been seen as 'the enemy'. While this is a normal part of the journey toward matching mind and body, it can be a dangerous mind set. It's true that nature may have made a mistake in pairing body and perceived self, but for as long as that body has breasts, they must be cared for.

As a part of the process of transition, many F.T.M.s choose to have top surgery which eliminates the need for concern about breast disease. It is currently unknown what effect a male hormone regimen has on the incidence of breast cancer in genetic females. It is known however, that there is a possibility of the occurrence of cancer or other benign breast disease as long as the female-to-male transsexual has breasts. It is important to regularly monitor breast health.

Male-to-female transsexuals or transgendered People

Amid all the storm and stress, misunderstanding and misinformation associated with changing one's sex/gender, probably the last thing an M.T.F. voyager wants to hear is that with the development of breasts there is also the chance of breast disease. Unfortunately, this is the case; but there is some encouraging news. According to Sheila Kirk, M.D., who is a leading authority on transgender health issues, the incidence of breast cancer in genetic males who are on feminizing hormones appears to be no greater than that of genetic males not on feminizing hormones. This is positive news because breast cancer in men is rare. Based on projections from the Komen Alliance, it was estimated that in the United States in 1996, 1,400 men would be diagnosed with the disease, and that 260 would die as a result.

However, before M.T.F.s conclude that they have little or nothing to worry about with regard to breast cancer, Dr. Kirk cautions that there are not enough long-term studies of breast disease in the M.T.F. population to dismiss the possibility of increased risk. She also suggests that possible risk factors such as high doses of oestrogen over many years, and the role of a family history of breast cancer need to be researched. But beyond the lack of studies on breast cancer, Dr. Kirk points out that M.T.F.s are subject to other, benign changes in their breasts; such as cysts, thickening, or other unusual tissue build-up. These changes should be detected and evaluated by a physician, according to Dr. Kirk, as they may be potential problem areas.

If you are at any point in the transition from male-to-female and have experienced breast development as a result of hormonal therapy, it might be wise to learn how to give yourself regular breast examinations to help safeguard against breast disease.

It would seem reasonable that M.T.F.s do everything they can to insure good breast health until, and after, ­more conclusive data is available. The basis for concern is, that if by some rare chance you do develop breast cancer, your survival is vitally dependent upon how early it is diagnosed and treated. This is crucial! Once the disease has developed, the survival rates are the same for genetic males and genetic females alike. That is why early detection is stressed.

Methods of Breast Examination

For the F.T.M. and the M.T.F., the primary methods for the detection of potential problems are: the clinical examination, the mammography, and the breast self-­examination.

The Clinical Examination

The clinical examination is performed by your physician or other health care professional at a check-up or office visit. This screening can be of great value since it is presumed that the practitioner has had special training or extensive experience in breast care. (Hopefully this is the case with your physician). The clinical exam is something every M.T.F. or genetic female would have at least once a year. Theoretically, it could be performed four or five times a year, but this usually isn't practical.

Mammography

Mammography, which is an x-ray of the breast, is the most effective screening method. It can detect growths the size of a pin head, long before they can be felt, but the frequency of this screening is once a year, or every two years, if it is done at all.

The Breast Self-Examination (B.S.E.)

The Breast Self-Examination (B.S.E.) is a combination of looking at and feeling the breasts, and is done by you. Unlike the frequency of the clinical exam and the mammography, this screening can be done whenever you want, most typically, every month. As you can see, the self-examination plays a central role in the early detection of disease because it is the most frequent screening. By doing it regularly you are, quite literally, taking responsibility for your breast health in your own hands.

The breast self-examination is a simple technique that just about anyone can perform. The object of it is, that through monthly practice you become so familiar with the usual geography of your breasts you'll quickly recognise any new or unusual change. If you do find something that is of concern, you can have your physician or health care professional evaluate it right away. However, before M.T.F.s conclude that they have little or nothing to worry about with regard to breast cancer, Dr. Kirk cautions that there are not enough long-term studies of breast disease in the M.T.F. population to dismiss the possibility of increased risk. B.S.E. can be considered a preventative health measure, along the lines of your regular dental checkups. The B.S.E. shouldn't be thought of as some grim procedure where you're on a search-and-destroy mission to find problems. For the M.T.F. it can be a pleasurable way of getting acquainted with your new body, a way to explore your breasts and be comfortable with them. They are, after all very tangible symbols of your feminine selves, and they should be a source of joy and pride! What better way to celebrate them than to take the time to check on their wellbeing.

The F.T.M. may take less pleasure in the B.S.E., but remember, your breasts are a part of you (albeit hopefully a temporary part), but as such, deserve proper care and attention.

No special equipment is needed to perform the breast self-examination other than a fairly large mirror and a pillow. It will also be necessary to have a warm, comfortable spot with good lighting, and without interruptions. Try to do the exam in the same place at the same time each month if possible; for example, prior to going to bed on each 15th of the month, or the last Sunday of every month. Before starting on your own program, you should have a complete clinical examination by your physician or health care professional. This way you'll begin with a clean slate, as it were, and establish a baseline condition on which to compare future self-exams.

A sample inventory might be for example, there is a small, brownish mole two inches under your left nipple; or a slightly lumpy feel of the upper right breast. (These will have been checked by your physician and found to be normal for you. In other words, you will have set a 'normal' condition for your breasts and you will then monitor any deviations from this condition.)

(A note to F.T.M.s who may still be menstruating. It is best to do the B.S.E. seven days after starting your period. Once the monthly cycle ceases, usually 3-6 months into the masculinising regimen, the B.S.E. can be performed at any time of the month)

Second Puberty and other Considerations

For those who have recently started feminizing hormonal therapy, or who have changed to a different regimen, there may be spurts of breast growth in short periods of time, just as an adolescent girl might experience going through puberty. You will most likely have to adapt your B.S.E. accordingly. This may also apply after sex reassignment surgery is performed. Once again, if you have specific questions consult with your health care professional.

Looking at the Breast

Take off your top and stand, or sit, in front of a mirror. Observe each breast for size and symmetry, texture and shape, skin colour, any moles or growths etc. Look at the nipple and the aureole (the coloured circle around the nipple). Raise both arms above your head and repeat the observations. Turn from side to side, observing the profiles. Tense your chest muscles by placing your hands on your hips and pressing in and again repeat the observations. Lean forward and look at the outline of each breast and nipple. Very gently squeeze each nipple and look for any discharge.

Feeling the Breasts, lying down

Lay down. Put a pillow under your left shoulder and your left arm behind your head. With your right hand, using the pads of your fingertips, feel your left breast. Make clockwise circles from the outer breast to the nipple or vice versa. Make up–and-down lines from top to bottom, or horizontal lines from side-to-side. Divide the breast into a clock-type pattern and work your way outward from the nipple with straight lines to each 'hour'. Or make up your own patterns. Just be sure you are thorough and that the whole breast is covered. Also, be consistent. Your finger tips will learn the topography of your breasts over time, and to change the patterns may send confused messages and make it impossible to judge from month to month. Use a combination of deep strokes, drawing the fingers over the breast to make sure you don't miss anything. If you are not sure what type of pressure to use, ask your health care professional. Feel along the armpit up to the collarbone for any swelling or enlarged lymph nodes. If the lymph nodes are swollen it could indicate a problem in the breast.

Move the pillow to under your right shoulder and place your right arm behind your head. Then use your left hand to repeat the process as for the right breast.

Feeling the Breasts, the Wet Look

Many authorities also recommend that you repeat the feeling process while in the shower or bath, as your soapy fingertips will glide more easily over the skin.

Start by raising your right arm behind your head. With your left hand, soaped fingers held flat together, roll and press the breast firmly against the chest wall. Using a circular motion, feel a small portion of the breast at a time, until the entire breast area including armpit and chest area from collarbone to below the breast have been checked. Repeat using firmer pressure. Now repeat, raising your left arm and checking your left breast with your right hand.

You're almost Finished

You're almost finished. The breast self-examination is as simple as that. With a little practice and repetition, you will become so familiar with the usual look and feel of your breasts that should anything unusual appear you can report it to your health care professional right away. But what should be considered 'unusual'? A lump, an inverted nipple, a discharge from a nipple, any swelling or dimpling of the skin, anything that wasn't there the last time your checked or that is of concern to you. Just keep in mind that if you do happen to discover something that deviates from the baseline you have established, the odds are that it will not turn out to be a serious problem or a cancer. But any questions you have, no matter how silly they may seem to you, should be discussed with your physician or health care professional. Only she or he can make a proper evaluation.

The B.S.E. and Breast Augmentation

For those (M.T.F. or F.T.M.) who have undergone a breast augmentation procedure and have implants, the breast self-examination should still be performed on a regular basis. Though the exam may be a bit more difficult, depending on where the implants are placed, the principle is still the same. Through regular practice you'll get to know the normal condition of your augmented breasts, and quickly notice something out of the ordinary. Of course, you should follow any special instructions your surgeon or physician may have given you concerning implants and your self-exam.

Other Health Concerns: Prostates and Pap Smears

A special note here to also remind Pre- and Post-Operative M.T.F. transsexuals of the fact that prostate cancer is the most common cancer in genetic males. Men and M.T.F.s over the age of fifty should have an annual health check-up that includes a prostate examination. Even after surgery it is important to have a periodic prostate examination, although it has been shown that after surgery and years of hormones the prostate decreases in size and no longer presents a danger.

These precautions can be very uncomfortable to follow through with, especially in view of the attitudes of many M.T.F.s concerning their unwanted body parts.

Similar feelings are experienced by F.T.M.s who need to continue periodic Pap smears. Perhaps F.T.M.s and M.T.F.s can take some comfort in the reasoning that going through transition and/or surgery is a wonderful step in the journey. Please take care of all of the parts to your body, wanted or not. How sad to be in the midst of the journey and to have it cut short by illness, or worse.

Testicle Self-Examination (T.S.E.)

Earlier, we spoke to F.T.M.s about the necessity of taking care of their breast health even if they 'hated' them and hoped to have them removed. It would be remiss of us not to talk openly to M.T.F.s who still have their male genitals, whether they plan to keep them or have sex reassignment surgery. Genetic males who are pre-operative transsexual or transgendered, need to be aware of the Testicle Self-Examination (T.S.E.).

Have a complete physical examination with your health care professional to establish a baseline of normality. Check your testicles once a month in the shower or bathtub, soap up your hands, roll each testicle between your thumb and forefinger. Feel for hard lumps and bumps. If you notice a change or have aches or lumps, seek medical help right away so something can be done about it. If you are uncircumcised, you need to remember to keep the area under the foreskin clean to avoid infection.

A Few Last Thoughts on Various Subjects

Like most things in life, taking responsibility for your breast and genital health is up to you. Learning the B.S.E. and B.S.E. and performing them monthly can not only give you peace of mind in knowing you're doing your part during your transsexual or transgendered journey. It can also save your life!

Polare Magazine is published quarterly in Australia by The Gender Centre Inc. which is funded by the Department of Family & Community Services under the S.A.A.P. program and supported by the N.S.W.Health Department through the AIDS and Infectious Diseases Branch. Polare provides a forum for discussion and debate on gender issues. Unsolicited contributions are welcome, the editor reserves the right to edit such contributions without notification. Any submission which appears in Polare may be published on our internet site. Opinions expressed in this publication do not necessarily reflect those of the Editor, The Gender Centre Inc., the Department of Family & Community Services or the N.S.W. Department of Health.

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