Gender identity refers to one’s personal sense of gender and includes identifying as cisgender (ie, a gender identity that aligns with the sex assigned at birth), transgender (ie, a gender identity that does not align with the sex assigned at birth), and gender nonconforming (GNC) (ie, a gender identity that does not follow others’ ideas about how a person should look or act based on the sex assigned at birth). There has been increasing national focus on examining cancer risks of transgender and gender-nonconforming (TGNC) patients1 and, although prior research has examined skin cancer prevalence among sexual minority populations,2 this study is the first, to our knowledge, to evaluate skin cancer history by gender identity.
This cross-sectional study analyzed data from annual Behavioral Risk Factor Surveillance System (BRFSS) surveys of adults aged 18 years and older from 2014 through 2018. Self-reported sex and skin cancer history were ascertained as described elsewhere.3 Gender identity was ascertained through BRFSS’s optional sexual orientation and gender identity module, which was introduced in 2014 and has since been administered in 36 US states. Respondents self-identified as cisgender, transgender (male to female or female to male), or GNC. We stratified cisgender respondents by sex and excluded respondents who answered “don’t know” or “not sure” or refused to answer any questions regarding sex, gender identity, or skin cancer history. This study was deemed exempt from review by the Partners Healthcare institutional review board because it used publicly available data. Accordingly, informed consent procedures were not required.
We weighted prevalence estimates to account for BRFSS’s complex survey design. We performed univariate regression analyses to determine associations between gender identity (Table 1) and other covariates (eTable in the Supplement) with skin cancer history. We performed multivariable logistic regression analyses to calculate adjusted odds ratios of skin cancer history by gender identity using R software, version 3.5.1 (R Foundation for Statistical Computing). A P value of .05 was used for statistical significance.
The unweighted study sample included 382 216 cisgender men, 511 231 cisgender women, 1240 transgender men, 1718 transgender women, and 791 GNC individuals (Table 2). Age-adjusted lifetime prevalence of skin cancer was 6.7% (95% CI, 6.6%-6.9%) among cisgender men, 5.8% (95% CI, 5.7%-6.0%) among cisgender women, 6.1% (95% CI, 3.9%-9.4%) among transgender men, 6.0% (95% CI, 4.3%-8.4%) among transgender women, and 6.8% (95% CI: 4.6%-10.0%) among GNC individuals (Table 1). Compared with cisgender men, adjusted odds ratios of skin cancer history were significantly lower among cisgender women (0.84 [95% CI, 0.81-0.87]), higher among GNC individuals (2.09 [95% CI, 1.02-4.28]) (Table 1), and not significantly different among transgender men or transgender women.
Compared with cisgender men, GNC individuals but not transgender men or women had a higher self-reported lifetime prevalence of skin cancer. While the reasons for this finding are unclear and require further evaluation, our leading hypothesis would be increased engagement in skin cancer risk behaviors. Cisgender women had significantly lower odds of lifetime prevalence of skin cancer than cisgender men, which is consistent with existing data on gender differences in skin cancer in the United States.4
These results are subject to 4 distinct limitations. First, because BRFSS’s sexual orientation and gender identity module was not administered in every state during each year, the findings may not be generalizable to the entire US population. Second, the study relied on self-reported skin cancer diagnoses and did not include data on risk factors, such as ultraviolet exposure, use of hormone replacement therapy,5 and HIV status. Third, the absolute event rate in TGNC populations was low compared with that of cisgender groups, yielding wide 95% CIs. Finally, although the lifetime prevalence estimates of skin cancer among transgender men and women were not different from that of cisgender men, disproportionately lower engagement in cancer screening behaviors and overall health care utilization6 by TGNC individuals compared with cisgender people may lead to fewer skin cancer diagnoses among TGNC individuals.
Additional studies are required to confirm these findings. Future research may identify avenues for public health intervention.
Accepted for Publication: December 4, 2019.
Published Online: February 12, 2020. doi:10.1001/jamadermatol.2019.4197
Correction: This article was corrected on June 3, 2020, to fix incorrect population numbers and missing data in the text and tables; the conclusions were unaffected by these errors.
Corresponding Author: Arash Mostaghimi, MD, MPA, MPH, Department of Dermatology, Brigham and Women’s Hospital, 221 Longwood Ave, Boston, MA 02115 (amostaghimi@bwh.harvard.edu).
Author Contributions: Mr Singer and Dr Hartman had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs Hartman and Mostaghimi were co–senior authors.
Concept and design: Singer, Tkachenko, Mostaghimi.
Acquisition, analysis, or interpretation of data: Singer, Tkachenko, Hartman.
Drafting of the manuscript: Singer.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Singer, Hartman.
Administrative, technical, or material support: Tkachenko, Mostaghimi.
Supervision: Mostaghimi.
Conflict of Interest Disclosures: Dr Hartman reported grants from American Skin Association during the conduct of the study. Dr Mostaghimi reported personal fees from Pfizer and 3Derm, equity from Lucid, personal fees and equity from Hims, and clinical trial support from Incyte, Lilly, Aclaris, and Concert outside the submitted work. No other disclosures were reported.
Disclaimer: Dr Mostaghimi is Associate Editor of JAMA Dermatology, but he was not involved in any of the decisions regarding review of the manuscript or its acceptance.
1.Burkhalter
JE, Margolies
L, Sigurdsson
HO,
et al. The national LGBT cancer action plan: a white paper of the 2014 National Summit on Cancer in the LGBT Communities.
LGBT Health. 2016;3(1):19-31. doi:
10.1089/lgbt.2015.0118Google ScholarCrossref 3.Singer
S, Tkachenko
E, Hartman
R, Mostaghimi
A. Lifetime prevalence of skin cancer diagnosis among gay, bisexual, and heterosexual individuals in the United States [published online February 5, 2020].
JAMA Dermatology. doi:
10.1001/jamadermatol.2019.4197Google Scholar 5.Cervenka
I, Mahamat-Saleh
Y, Dartois
L, Boutron-Ruault
M-C, Fournier
A, Kvaskoff
M. Exogenous hormone use and cutaneous melanoma risk in women: the European prospective investigation into cancer and nutrition.
Rev Epidemiol Sante Publique. 2018;66:S253. doi:
10.1016/j.respe.2018.05.051Google ScholarCrossref