Natalie Jeffery, an Atlanta-based trans woman and drag artist, made herself a resolution for 2018: She was going to do hormone replacement therapy the right way this year…with a doctor.
Jeffery performs as “Mo'Dest Volgare,” a ratchet queen with stripper couture style, living the EBT life. In 2015, Mo'Dest shocked audiences by coming out as trans on stage. In the middle of a lip sync to “Time To Change” by the Brady Bunch, she pulled out a vial of estrogen (that she'd obtained from a friend) and injected herself in front of the audience. She made the statement that, even if she lives off tips and doesn't have health insurance, she can still find a way to afford her truth. By 2018, Jeffery had run out of second-hand estrogen and had a choice: She could buy hormones from India, and accept their risk, or she could figure out a way to pay for mainstream medical treatment at the local public hospital. By now she was sure of her dedication to transitioning. Life was looking up. She was finally becoming a woman for good. That's when her doctor told her that she had testicular cancer.
This was not the result of her being trans or taking hormones. The lump showed up prior to her transition. She was 28, the age at when symptoms often begin to show on people with testicular cancer. It also happened to be when she committed to transitioning.
“I'd had a lump on my testicle for years,” Jeffery says. “In the past year or two it got very large and even got to the point where I couldn't tuck for drag anymore. But I’m ready to wear catsuits again.”
Even though her testicular cancer may get in the way of her drag career, it's not getting in the way of her transition. As she moves forward with cancer treatment, which will likely involve removing the testicle, her doctor has okayed her to continue on hormone replacement therapy (HRT).
Cancer in trans women and men is a mostly unstudied field; it's an area of knowledge in dire need of research, says Jess Ting, the director of surgery for Mount Sinai Center for Transgender Medicine and Surgery. Ting pioneered this new position at Mount Sinai just two and a half years ago. He says that prior to 2016, there was no place in New York City (the biggest, arguably most cosmopolitan city in the US) to get genital reconstruction, aka “bottom surgery." Ting says that medicine is just now catching up to the realities of trans health, and today's trans people are the generation whose experience will define the first wide-ranging studies of trans healthcare.
“It's very common for patients to say they were on black-market hormones for 20 years, and only recently have received HRT from a doctor,” Ting tells me. “You went to a doctor 20 years ago and they didn't know how to treat you, they misgendered you, and many trans people avoided the health system.”
In terms of cancer, Ting has to rely on best practices from other fields to treat his trans patients. There are no longitudinal studies about the relationship between HRT and other health risks, particularly cancer. It's been shown that HRT in cis women can increase the risk of breast cancer. But for trans women, it's unstudied and unknown. If trans women have taken illicit hormones, sometimes for decades, the risk is even more unknown.
Estrogen from India may be higher- or lower-dosage than indicated, it may be contaminated with carcinogens, or it may not even be estrogen at all. All these variables make studying cancer risk in trans women all the more complex. “In terms of breast cancer, trans women need to be screened just like cisgender women. They need to follow the same guidelines until we know better. At this point, it's better to be safe than sorry,” Ting says.
For women, the current guidelines are to get an initial mammogram at age 45, if they have increased risk factors (such as a family history of cancer), and initial screening at age 50 for everyone else. Afterwards, women should receive annual mammograms.
Ting says that a silver lining of the uncertainty of cancer risk in trans women is that they are probably at a much lower risk for prostate cancer. Testosterone suppression is part of treating prostate cancer, and prostates usually shrink during HRT and vaginoplasty (bottom surgery for trans women). He adds that no matter what type of vaginoplasty a patient has—Penile Inversion Vaginoplasty or Rectosigmoid Vaginoplasty (which uses part of the colon to create a vaginal lining)—a trans woman still has a prostate. “Trans women [who have had vaginoplasty] should get pelvic exams every year, and this easily includes a prostate exam,” he tells me.
For doctors, it can be a challenge to discuss cancers that don't line up with their patients' gender identities. For example, if a trans man has not had a hysterectomy, discussing his uterus and ovarian system may bring up intense emotional pain. Ting says it's vital that doctors meet their trans patients where they are, and be flexible with the words they use to describe themselves.
“First, you should always ask them what pronouns they preferred to be called. Then use the words they use to describe their body. When in doubt, ask your patient, ‘how do you want me to [refer to] these body parts?’”
Ting hopes that more money and research (or more accurately, any money and research) will get spent on understanding trans health issues. As one of the most marginalized sections of society, they've generally been ignored by the health system and have had to find their own road. For Jeffery, this is all too true. She has no familial support, and is going into cancer treatment with the support of other trans women and drag queens she knows. While the cancer has not spread to her organs, it might have moved to her lymph nodes. She, her doctors, and her community are trying their best to make it through this. That’s all they can do.
“I have no safety net except my community. I have a close group of friends and also a bunch of fans. We are planning some charity shows and I have a GoFundMe,” she says. Some people might see Jeffery's testicular cancer as a sign she was meant to be a woman. She was meant to have a vagina. But Jeffery doesn't see her life and body in those terms.
“Altering my genitals isn’t something I have put too much thought into. It’s very expensive and not really something anyone sees so I haven’t made plans," she says. "But I’m certainly not getting replacement balls. When they are gone, they are gone.”
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