By continuing to use our site, you agree to our Privacy Policy and Terms of Use.
Prostate cancer affects cisgender men, intersex, nonbinary and transgender people.
After President Joe Biden's stunning cancer diagnosis, The Advocate asked medical experts what the LGBTQ+ community should know about this disease.
On Sunday, a short statement from the personal office of former President Joe Biden stunned the country and unsettled many, including LGBTQ+ Americans.
Keep up with the latest in LGBTQ+ news and politics. Sign up for The Advocate's email newsletter.
“Last week, President Joe Biden was seen for a new finding of a prostate nodule after experiencing increasing urinary symptoms,” the statement read. “On Friday, he was diagnosed with prostate cancer, characterized by a Gleason score of 9 (Grade Group 5) with metastasis to the bone.”
The cancer is aggressive, but “appears to be hormone-sensitive,” a factor that doctors say “allows for effective management.”
To many, it felt sudden. Although he pulled out of the presidential election over concerns about his mental acuity in July, just five months earlier, in February 2024, Biden had been described in his official White House physical as “a healthy, active, robust 81-year-old male.” That report, signed by Dr. Kevin O’Connor, mentioned no concerns about concerns over prostate-specific antigen (PSA) levels (proteins made by cells in the prostate gland) or prostate health, only stable conditions like atrial fibrillation, acid reflux, arthritis, and peripheral neuropathy.
But beneath that surface of apparent stability lies a truth LGBTQ+ patients know all too well: Cancer, especially prostate cancer, often progresses silently. And in gay, bisexual, and other men who have sex with men, as well as transgender women, nonbinary people, and intersex populations, the risk of being overlooked is often embedded in systems unequipped to care for diverse bodies and identities.
Prostate cancer is a cancer that begins in the prostate — a small gland that's found below the bladder that supports the creation of semen. It's part of the reproductive system for most people who are assigned male at birth.
It's also one of the most common types of cancer, according to the Mayo Clinic. "Prostate cancer is usually found early, and it often grows slowly. Most people with prostate cancer are cured," its website states.
A Gleason score is a method of describing prostate cancer. It's based, according to the National Cancer Institute, on cancer cells present and the chance of them growing and spreading. Those cancer cells themselves could have different grades.
So, "the Gleason score is calculated by adding together the two grades of cancer cells that make up the largest areas of the biopsied tissue sample," the institute states on its website.
The score is usually between 6 to 10.
"The lower the Gleason score, the more the cancer cells look like normal cells and are likely to grow and spread slowly. The Gleason score is used to help plan treatment and determine prognosis (outcome)," according to the institute.
Dr. Stephen Freedland, a prostate cancer expert and professor of urology at Cedars-Sinai Medical Center in Los Angeles, told The Advocate that Biden’s case, while uncommon, is not unheard of.
“So often these aggressive tumors that have spread to the bones are found in people who had missed screenings or never been screened,” Freedland said. “But we definitely do see it in patients that are routinely screened, and either the PSA was not going up and all of a sudden takes off, or had been going up slowly and not fast enough to raise any alarms, but then all of a sudden jumps.”
That kind of diagnostic whiplash is part of what makes prostate cancer so unnerving. And for LGBTQ+ people, the risks of being missed — or misread — are heightened by both medical gaps and cultural neglect.
PSA is a protein measured through a blood test to help detect prostate cancer. But because its production depends on testosterone, interpreting PSA levels isn’t straightforward for everyone.
“For those on estrogen therapy, the net result is it lowers testosterone down to castrate levels,” Freedland explained. “And to make PSA, you need testosterone. So the PSAs are extremely low in those patients.”
Freedland coauthored a 2024 JAMAstudy with Dr. Farnoosh Nik-Ahd, a senior resident at the University of California, San Francisco, Medical Center, analyzing PSA values in transgender women on gender-affirming hormones. They found that the median PSA in that group was 0.02 — a stark contrast to cisgender men of similar age, whose median PSA hovers closer to 1.0. Over a third of the transgender women had undetectable PSA levels.
“This highlights the importance of prostate cancer awareness amongst all patients,” Nik-Ahd told The Advocate. “Transgender women, too, are part of the population who remain at risk — whether they’ve undergone a vaginoplasty or any other gender-affirming surgery, they still retain their prostate and should discuss PSA screening with their clinicians.”
Because hormone therapy suppresses testosterone, the traditional PSA cutoff of 4.0 may be dangerously high for those on estrogen. “We suggested maybe a 0.5 or 0.6, almost tenfold lower is the right measure,” Freedland said.
This updated threshold is now reflected in the 2025 National Comprehensive Cancer Network Prostate Cancer Early Detection guidelines, which advise clinicians to interpret PSA values with greater care in transgender patients.
Kelly Haviland, chief nursing officer at New York Cancer and Blood Specialists and a leader in LGBTQ+ cancer care, told The Advocate that even seasoned clinicians often don’t know what to do when it comes to screening transgender women who are or have medically transitioned.
“I asked a group of surgeons where they send patients post-op for prostate screening, and they were stumped,” she said, referring to trans women who had undergone gender-affirming bottom surgery. “The prostate is still there, usually palpable on the anterior wall of the neovagina. But it’s missed all the time.”
She said that because people on estrogen often have prostates that atrophy over time and may seem of normal size during a digital rectal exam. However, a normal-sized prostate for that patient could be considered significantly enlarged.
That disconnect is not just a clinical issue — it’s a life-threatening one. “Many patients simply don’t know what their prostate cancer risk is. Many providers don’t either,” Haviland said.
Al Asante-Facey, associate director of advanced practice providers for subspecialty medicine at Memorial Sloan Kettering and a clinician in its LGBTQI+ Cancer Program, emphasized that without recorded sexual orientation and gender identity data, transfeminine people are rendered invisible in cancer risk models.
“The LGBT+ identity is invisible in health care data unless SOGI data is recorded,” they told The Advocate.
Jenna Coluccio, a physician assistant who manages the solid tumor genitourinary oncology APP team at Memorial Sloan Kettering, said that despite the frightening label of “Stage 4,” many patients live well with advanced prostate cancer.
“Although the term ‘Stage 4’ can sound frightening and is often associated with incurable prognosis, many patients with advanced disease can still lead fulfilling lives,” she said. “With the right systemic treatments, it can be managed as a chronic condition.”
Even for cisgender queer men, prostate cancer care often fails to account for their lived realities. “We don’t talk about penetration. We don’t talk about rigidity. We don’t talk about changes in ejaculate,” Haviland said. “People are left feeling ashamed and alone, especially when they’re not given information about what [prostate cancer] treatment might change.”
Asante-Facey noted that some treatments may reduce anal sensation or impact erection quality — issues that disproportionately affect men who have sex with men. “It’s important to have frank conversations about this so people can make informed decisions,” they said.
Haviland urged clinicians and public health leaders not to forget intersex patients in the conversation around prostate cancer.
“There is no binary,” she said. “We are not binary people. There are a variety of us all over with different parts, but we all deserve care.”
Many intersex individuals may have prostates and not know it, particularly if they were assigned female at birth and subjected to early surgical intervention. “So if we’re not asking about what organs a person actually has, we risk missing the opportunity to screen them altogether,” Haviland said.
In practice, this means clinicians must move beyond assumptions and ask straightforward, respectful questions about anatomy, hormonal therapy, and surgical history.
“We have to ask what hormones you’re producing, what organs you have that need to be screened for cancer,” she said.
Freedland recommends PSA screening begin around age 40, not 55.
“It doesn’t necessarily have to be every year. It can be every few years when you’re in your 40s,” he said. “But I think a baseline blood test around age 40 is probably the best thing that we can do.”
Asante-Facey added that providers must do better at building trust.
“The most important aspect of health care is having a provider that you trust and can be open and honest with,” they said. “To provide high-quality cancer care, your health care provider must be able to see who you are as a whole person.”
As Biden begins treatment, Freedland emphasized that the former president’s prognosis reflects years of medical progress.
“The outcomes for someone like President Biden are much better than in the past due to the investment in medical research,” he said. “We need to highlight that all of the investment we have done in medical research has allowed us to find these tumors better and treat them better.”
In recent months, the Department of Health and Human Services under President Donald Trump and HHS Secretary Robert F. Kennedy Jr. has cut funding for research projects at the National Institutes of Health, including cancer research.
“We won’t be able to really screen people in a manner that’s helpful unless we have research. We have nothing without research. Cutting funding means erasing us," Haviland said.
