European radiologists are now navigating the early implementation of the July 2025 French National Authority for Health guidance on care for transgender adults, one of the clearest recent frameworks for long-term follow-up in this population.
The ECR 2026 session highlighted a shift from access to follow-up, with increasing focus on how imaging pathways reflect retained organs, surgical history, and hormone exposure.
This marks a shift from earlier discussions in the field, which largely focused on breast care inclusion and patient experience, including prior reporting on transgender breast imaging, as outlined in an interview with Dr. Anna D’Angelo, consultant radiologist at the Foundation Polyclinic University A. Gemelli in Rome.
This time, the discussion moved deeper into diagnostic workflow: who gets invited to screening, how altered anatomy changes interpretation, and what happens when familiar markers such as prostate-specific antigen become harder to trust.
From access to follow-up
“Transgender patients report many more negative experiences during imaging encounters than during other general health encounters,” said Ramona Anna Woitek, MD, PhD, MBA.Courtesy of Claudia Tschabuschnig
Non-neoplastic disease and postoperative anatomy are key areas of focus for Ramona Anna Woitek, MD, PhD, of Danube Private University and the Medical Imaging Analysis and Artificial Intelligence Research Center in Wiener Neustadt, Austria, as radiologists are increasingly required to interpret unfamiliar, surgically altered anatomy and distinguish expected postoperative appearances from true complications or pathology.
Cancer screening in transgender patients should be guided primarily by retained organs, prior surgery, and endocrine context, argued Patricia Andrea Gutierrez, MD, of CH Dunkerque in Dunkirk, France, who then focused on genitourinary tumors. In practice, however, screening pathways are still frequently determined by administrative sex markers, creating a mismatch that can result in patients being missed by screening programs or assessed using the wrong clinical pathway.
The gap is already visible in public screening guidance. Cancer Research UK notes that the way sex or gender is recorded with a GP determines which screening invitations are sent automatically. In practice, this means some patients with a cervix may not be called for cervical screening if they are registered as male, while others may receive invitations for tests no longer relevant to their anatomy. Speakers used that mismatch to underline a broader point: even small or underserved populations require evidence-based, organ-specific pathways.
When standard markers get shaky
“Cancer risk persists as long as the organ persists,” noted Patricia Andrea Gutierrez, MD, CH Dunkerque, Dunkirk, France.Courtesy of Claudia Tschabuschnig
Gutierrez stressed that hormone therapy can distort the signals clinicians usually rely on. In transgender men, testosterone-induced amenorrhea does not eliminate endometrial risk. Endometrial atrophy may be common, but it is not universal, and abnormal bleeding remains a red flag that may warrant ultrasound, biopsy, or MRI when pelvic examination is limited by dysphoria or anatomy.
In transgender women, the prostate usually remains after vaginoplasty, and prostate cancer risk is not removed. Prostate Cancer UK notes that PSA levels after feminizing hormones or orchidectomy are lower than in cis men, which can make a “normal” result falsely reassuring. Gutierrez argued that this is exactly where multiparametric MRI becomes more important, especially when digital rectal examination is altered by postoperative anatomy.
Keeping patients in the system
Woitek reviewed complications after vaginoplasty and phalloplasty, including abscesses, fistulas, strictures, residual erectile tissue, and neovaginal prolapse. Gutierrez extended that discussion into oncology, noting that altered pelvic anatomy can affect biopsy routes, surgery, and radiation planning. In transgender women, for example, neovaginal tissue and the surrounding structures may become relevant not only for interpretation, but also for procedural planning and safety.
That technical complexity lands in a field where patient avoidance is still common. In December 2025, ESR survey data showed that 25% of transgender and nonbinary patients had negative encounters with radiology staff, often involving poor privacy protection or disregard for comfort. The result is a pattern the ECR session made plain: when screening systems miss people and examinations are delayed, radiology may become the first place where disease is finally seen.
Screening in transgender patients cannot be reduced to a gender label in the medical record. For radiologists, the task is to integrate anatomy, hormonal context, and oncologic risk and to recognize when standard pathways no longer apply and adjust them accordingly.
As implementation of new national frameworks such as the French HAS guidance progresses, radiology departments may need to adapt intake processes, reporting practices, and training to reflect organ-based risk rather than binary classification.
