Skip to main content

Incidence of breast cancer in a cohort of 5,135 transgender veterans


Transgender (TG) persons often receive, or self-treat, with cross-sex hormone (CSH) treatments as part of their treatment plans, with little known about their incidence of breast cancer. This information gap can lead to disparities in the provision of transgender health care. The purpose of the study was to examine the incidence of breast cancer in the largest North American sample of TG patients studied to date to determine their exposure to CSH, incidence of breast cancer, and to compare results with European studies in transsexual populations. We used Veterans Health Administration (VHA) data from 5,135 TG veterans in the United States from 1996 to 2013 to determine the incidence of breast cancer in this population. Chart reviews were completed on all patients who developed breast cancer. Age-standardized incidences of breast cancer from the general population were used for comparison. Person-years of exposure to known CSH treatment were calculated. Ten breast cancer cases were confirmed. Seven were in female-to-male patients, two in male-to-female patients, and one in a natal male with transvestic fetishism. Average age at diagnosis was 63.8 (SD = 8.2). 52 % received >1 dose of CSH treatment from VHA clinicians. All three males presented with late-stage disease were proved fatal. The overall incidence rate was 20.0/100,000 patient-years of VHA treatment (95 % CI 9.6–36.8), irrespective of VA CSH treatment. This rate did not differ from the expected rate in an age-standardized national sample, but exceeded that reported for smaller European studies of transsexual patients that were longer in duration. Although definitive conclusions cannot be made regarding breast cancer incidence in TG veterans who did or did not receive VA CSH due to the sample size and duration of observation, it appears that TG veterans do not display an increase in breast cancer incidence. This is consistent with European studies of longer duration that conclude that CSH treatment in gender dysphoric patients of either birth sex does not result in a greater incidence than the general population.

This is a preview of subscription content, access via your institution.


  1. Benjamin H (1964) Clinical aspects of transsexualism in the male and female. Am J Psychother 18:458–469

    CAS  PubMed  Google Scholar 

  2. Benjamin H (1966) The transsexual phenomena. Julian Press, New York

    Google Scholar 

  3. Symmers WC (1968) Carcinoma of the breast in trans-sexual individuals after surgical and hormonal interference with the primary and secondary sex characteristics. Br Med J 2:83–85

    CAS  PubMed Central  PubMed  Article  Google Scholar 

  4. Dhand A, Dhaliwal G (2010) Examining patient conceptions: a case of metastatic breast cancer in an African American male to female transgender patient. J Gen Intern Med 25:158–161

    PubMed Central  PubMed  Article  Google Scholar 

  5. Nikolic DV, Djordjevic ML, Granic M, Nikolic AT, Stanimirovic VV, Zdravkovic D, Jelic S (2012) Importance of revealing a rare case of breast cancer in a female to male transsexual after bilateral mastectomy. World J Surg Oncol 1:280

    Article  Google Scholar 

  6. Shao T, Grossbard ML, Klein P (2011) Breast cancer in female-to-male transsexuals: two cases with a review of physiology and management. Clin Breast Cancer 11:417–419

    PubMed  Article  Google Scholar 

  7. Gooren L (2011) Care of transsexual persons. N Engl J Med 364:1251–1257

    CAS  PubMed  Article  Google Scholar 

  8. Asscheman H, Giltay EJ, Megens JA, de Ronde WP, van Trotsenburg MA, Gooren LJ (2011) A long-term follow-up study of mortality in transsexuals receiving treatment with cross-sex hormones. Eur J Endocrinol 164:635–642

    CAS  PubMed  Article  Google Scholar 

  9. Gooren LJ, van Trotsenburg MA, Giltay EJ, van Diest PJ (2013) Breast cancer development in transsexual subjects receiving cross-sex hormone treatment. J Sex Med 12:3129–3134. doi:10.1111/jsm.12319

    Article  Google Scholar 

  10. van Kesteren PJ, Asscheman H, Megens JA, Gooren LJ (1997) Mortality and morbidity in transsexual subjects treated with cross-sex hormones. Clin Endocrinol (Oxf) 47:337–342

    Article  Google Scholar 

  11. Wierckx K, Mueller S, Weyers S et al (2012) Long-term evaluation of cross-sex hormone treatment in transsexual persons. J Sex Med 9:2641–2651

    CAS  PubMed  Article  Google Scholar 

  12. U.S. Department of Veterans Affairs. National Center for Veterans Analysis and Statistics (2013) Trends in the utilization of VA programs and services

  13. U.S. Veterans Affairs, Veterans Health Administration: VHA Directive 2011–026: Providing Health Care for Transgender and Intersex Veterans (2011). Accessed on 12 May 2014

  14. U.S. Veterans Affairs, Veterans Health Administration: VHA Directive 2013-003: Providing Health Care for Transgender and Intersex Veterans (2013). Accessed on 12 May 2014

  15. Lamoreaux J (1996) The organizational structure for medical information management in the Department of Veterans Affairs: an overview of major health care databases. Med Care 34(suppl):31–44

    Article  Google Scholar 

  16. West AN, Lee RE, Shambaugh-Miller MD, Blair BD, Mueller KJ, Lilly RS, Kaboli PJ, Hawthorne K (2010) Defining “rural” for veterans’ health care planning. J Rural Health 26:301–309

    PubMed  Article  Google Scholar 

  17. VA Information Resource Center: Vital Status File Date of Birth (DOB) and Sex Quality Review. Hines, IL: U.S. Dept. of Veterans Affairs, Health Services Research and Development Service, VA Information Resource Center. Accessed on 2 June 2014

  18. World Health Organisation International Statistical Classification of Diseases and Related Health Problems, 9th Revision (ICD-9-CM) (1978) Geneva

  19. Surveillance, epidemiology, and end results program, SEER incidence rates and U.S. Death Rates, Age-Adjusted and Age-Specific Rates, by Race and Sex (Breast) (2014). Washington, DC. National Cancer Institute. Accessed on 24 June 2014

  20. Howlader N, Noone AM, Krapcho M, Garshell J, Neyman N, Altekruse SF, Kosary CL, Yu M, Ruhl J, Tatalovich Z, Cho H, Mariotto A, Lewis DR, Chen HS, Feuer EJ, Cronin KA (eds). SEER cancer statistics review, 1975–2010 National Cancer Institute: Bethesda, MD., based on November 2012 SEER data submission, posted to the SEER Web site, April 2013. Accessed on 9 July 2014

  21. R Development Core Team (2010) R: a language and environment for statistical computing. R Foundation for Statistical Computing, Vienna

    Google Scholar 

  22. Coleman E, Bockting W, Botzer M, Cohen-Kettenis P, DeCuypere G, Feldman J, Fraser L, Green J, Knudson G, Meyer WJ, Monstrey S, Adler RK, Brown GR, Devor AH, Ehrbar R, Ettner R, Eyler E, Garofalo R, Karasic DH, Lev AI, Mayer G, Meyer-Bahlburg H, Hall BP, Pfaefflin F, Rachlin K, Robinson B, Schechter LS, Tangpricha V, van Trotsenburg M, Vitale A, Winter S, Whittle S, Wylie KR, Zucker K (2012) Standards of care for the health of transsexual, transgender, and gender-nonconforming people, Version 7. Int J Transgenderism 13:165–232

    Article  Google Scholar 

  23. Makadon HJ, Mayer KH, Potter J (2007) Fenway guide to lesbian, gay, bisexual and transgender health, 1st ed. American College of Physicians, Philadelphia, PA, pp 3–22(35–36):331–392

    Google Scholar 

  24. Burcombe RJ, Makris A, Pittam M, Finer N (2003) Breast cancer after bilateral subcutaneous mastectomy in a female-to-male trans-sexual. Breast 12:290–293

    CAS  PubMed  Article  Google Scholar 

  25. Gethins M (2012) Breast cancer in men. J Natl Cancer Inst 104:436–438

    PubMed  Article  Google Scholar 

  26. Giordano S, Buzdar A, Hortobagyi G (2002) Breast cancer in men. Annals Intern Med 137:678–687

    Article  Google Scholar 

  27. American Cancer Society. Cancer facts and figures (2014). American Cancer Society, Atlanta

  28. Thomas DB (1993) Breast cancer in men. Epidemiol Rev 15:220–231

    CAS  PubMed  Google Scholar 

  29. Guenel P, Cyr D, Sabroe S, Lynge E, Merletti F, Ahrens W, Baumgardt-Elms C, Menegoz F, Olsson H, Paulsen S, Simonato L, Wingren G (2004) Alcohol drinking may increase risk of breast cancer in men: a European population-based case-control study. Cancer Causes Control 15:571–580

    PubMed  Article  Google Scholar 

  30. Collaborative group on Hormonal Factors in Breast Cancer (2002) Alcohol, tobacco and breast cancer-collaborative reanalysis of individual data from 53 epidemiological studies, including 58 515 women with breast cancer and 95,067 women without the disease. Br J Cancer 87:1234–1245

    PubMed Central  Article  Google Scholar 

  31. Hedlund PO (2000) Side effects of endocrine treatment and their mechanisms: castration, antiandrogens, and estrogens. Prostate Suppl 10:32–37

    CAS  PubMed  Article  Google Scholar 

  32. Evans DG, Susnerwala I, Dawson J, Woodward E, Maher ER, Lalloo F (2010) Risk of breast cancer in male BRCA2 carriers. J Med Genet 47:710–711

    CAS  PubMed  Article  Google Scholar 

  33. Tai YC, Domchek S, Parmigiani G, Chen S (2007) Breast cancer risk among male BRCA1 and BRCA2 mutation carriers. J Natl Cancer Inst 99:1811–1814

    CAS  PubMed Central  PubMed  Article  Google Scholar 

  34. Rossouw JE, Anderson GL, Prentice RL, LaCroix AZ, Koopersberg C, Stefanick ML, Jackson RD, Beresford SA, Howard BV, Johnson KC, Kotchen JM, Ockene J (2002) Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women’s Health Initiative randomized controlled trial. J Am Med Assoc 288:321–333

    CAS  Article  Google Scholar 

  35. Jemal A, Ward E, Thun MJ (2007) Recent trends in breast cancer incidence rate by age and tumor characteristics among U.S. women. Breast Cancer Res 9:R28

    PubMed Central  PubMed  Article  Google Scholar 

  36. Ravdin PM, Cronin KA, Howlader N, Berg CD, Chlebowski RT, Feuer EJ, Edwards BK, Berry DA (2007) The decrease in breast-cancer incidence in 2003 in the United States. N Engl J Med 356:1670–1674

    CAS  PubMed  Article  Google Scholar 

  37. Mepham N, Bouman W, Arcelus J, Hayter M, Wylie K (2014) People with gender dysphoria who self-prescribe cross-sex hormones: prevalence, sources, and side effects knowledge. J Sex Med. doi:10.1111/jsm.12691

    PubMed  Google Scholar 

  38. Burgess H, Shousha S (1993) An immunohistochemical study of the long-term effects of androgen administration on female-to-male transsexual breast: a comparison with normal female breast and male breast showing gynaecomastia. J Pathol 170:37–43

    CAS  PubMed  Article  Google Scholar 

  39. Shufelt CL, Braunstein GD (2008) Testosterone and the breast. Menopause Inter 14:117–122

    Google Scholar 

  40. Vujović S, Popović S, Milošević-Sbutega G, Đorđević M, Gooren LJG (2009) Transsexualism in Serbia: a twenty-year follow-up study. J Sex Med 6:1018–1023

    PubMed  Article  Google Scholar 

  41. Xavier JM, Bobbin M, Singer B, Budd E (2005) A needs assessment of transgendered people of color living in Washington, DC. Int J Transgenderism 8:31–47

    Article  Google Scholar 

  42. Easton DF, Bishop DT, Ford D, Crockford GP (1993) Genetic linkage analysis in familial breast and ovarian cancer: results from 214 families. The breast cancer linkage consortium. Am J Hum Genet 52:678–701

    CAS  PubMed Central  PubMed  Google Scholar 

  43. Deutsche M, Green J, Keatley J, Mayer G, Hastings J, Hall A (2013) Electronic medical records and the transgender patient: recommendations from the World Professional Association for Transgender Health EMR working group. J Am Med Inform Assoc 20:700–703

    Article  Google Scholar 

  44. Hembree WC, Cohen-Kettenis P, Delemarre-van de Waal HA, Gooren LJ, Meyer WJ III, Spack NP, Tangpricha V, Montori VM (2009) Endocrine treatment of transsexual persons: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 94:3132–3154

    CAS  PubMed  Article  Google Scholar 

  45. Delemarre-van de Waal H, Cohen-Kettenis P (2006) Clinical management of gender identity disorder in adolescents: a protocol on psychological and paediatric endocrinology aspects. Eur J Endocrinol 155:S131–S137

    CAS  Article  Google Scholar 

  46. Gooren LJ, Giltay EJ, Bunck MC (2008) Long-term treatment of transsexuals with cross-sex hormones: extensive personal experience. J Clin Endocrinol Metab 93:19–25

    CAS  PubMed  Article  Google Scholar 

Download references


Walter Meyer, MD, provided helpful comments on a draft of this document. This work did not receive Grant funding.

Conflict of interest

The authors were not sponsored by any commercial entity or any agency other than their employer, the Veterans Health Administration, and therefore they have no conflicts of interest to report with respect to this work.

Ethical standards statement

This work was approved by the East Tennessee State University Institutional Review Board.

Author information

Authors and Affiliations


Corresponding author

Correspondence to George R. Brown.

Additional information

The views expressed in this manuscript are those of the authors and do not necessarily represent those of the United States Government, the Veterans Health Administration, or East Tennessee State University.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Brown, G.R., Jones, K.T. Incidence of breast cancer in a cohort of 5,135 transgender veterans. Breast Cancer Res Treat 149, 191–198 (2015).

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI:


  • Transgender
  • Breast
  • Cancer
  • Veteran
  • Gender identity
  • Gender dysphoria
  • Hormones