AMA Journal of Ethics^®

Abstract

Cervical cancer is most frequently diagnosed in patients ages 35 to 44, but risk persists as individuals age. Among patients who are regularly screened via the Pap test, cancer is rare and death rates have dropped dramatically in the United States. Nevertheless, access to regular screening can be difficult for transgender men (individuals assigned female at birth but with a male gender identity) due to misinformation, discomfort scheduling appointments, fear of being mistreated or of refused services, lack of insurance, and clinicians’ lack of knowledge. This narrative explores 6 barriers to cervical cancer screening for transgender men and offers recommendations for eliminating cervical cancer inequality.

Need for Transgender Gynecological Care

Death rates from cervical cancer have dropped dramatically in the United States due to the effectiveness of the Pap test in detecting cervical cancer, which has allowed clinicians to treat abnormal and precancerous cells.^1,2,3 Yet transgender men (individuals assigned female at birth but with a male gender identity) obtain cervical cancer screening less frequently and are less likely to be up-to-date on Pap tests than cisgender women (individuals assigned female at birth and with a female gender identity).⁴ According to the 2015 US Transgender Survey, although transgender men are vulnerable to chronic undetected human papillomavirus (HPV) infections, only 27% report having had a Pap smear in the past year compared to 43% of women in the general population.⁵ Barriers like the ones presented below may prevent transgender men from scheduling appointments and accessing life-saving screenings. First, however, I offer a personal perspective on the need for cancer screening.

Testosterone Therapy and Pelvic Pain

During the summer of 2006, I celebrated the completion of my first year on testosterone. Over the course of that year, I documented many physical changes as my body morphed from a female to male shape. I had undergone chest surgery (a bilateral mastectomy with nipple grafts), but I still had other body parts—uterus, ovaries, fallopian tubes, vagina, and cervix—that required screening typically marketed only to female patients. The last time I had had a pelvic exam and Pap test, I was 19 years old, and I was now turning 26. Although cervical cancer is most frequently diagnosed in patients ages 35 to 44,¹ it was important to me to schedule another exam, not only to make sure that my tissues were healthy but also to address my ongoing extreme pelvic pain.

After initiating hormone therapy—in my case, testosterone—transgender male patients can experience cramping and pain that can last more than 6 months.⁶ My pelvic pain had been ongoing day and night for almost 4 weeks. At the time, I didn’t know that this was a common symptom of testosterone use,⁵ so I was concerned. Although motivations and reasons for seeking gynecological care vary, in my case, I had dysphoria about my reproductive organs; I was tired of dealing with pelvic pain; and I was concerned about uterine, cervical, and ovarian cancer. (Please note that there is currently no evidence that testosterone therapy increases risk for ovarian, uterine, or cervical cancers among transgender men.⁷) Not having a desire to retain my uterus, I hoped my exam would render me eligible for a laparoscopic total hysterectomy and an oophorectomy. If so, I would be joined by a low percentage of transgender men who have had a hysterectomy. In a 2015 survey that included more than 8000 trans male respondents, 14% reported having had a hysterectomy and 57% reported wanting one someday.⁵

Barriers

1: Gynecological care for men. Scheduling an appointment for gynecological care, including a Pap test and pelvic exam, and then following through with the appointment can be emotionally difficult for transgender men. I wanted to see a clinician about my concerns, but I was afraid to call and schedule an appointment because I didn’t know if anyone would take me as a patient. I’d had negative experiences with clinicians and staff in the past, so even if someone would see me, I was worried about how I’d be treated.

I gained courage by having a female friend call her obstetrician’s gynecology office and ask if anyone would see a trans man as a patient. The office responded, “We’ve never worked with a trans man before, but send him our way!” It was a relief to hear this kind of response in 2006, given the lack of clinical education and training in how to respond to transgender patients’ obstetrics and gynecological needs.⁸ This lack of training persists. A 2015 survey of obstetrics and gynecology clinicians found that 80% of respondents reported not having received training in transgender care during residency, but almost 89% reported that they would be willing to provide routine Pap tests for transgender men.⁸ In my case, knowing the clinic was open to me, even if its staff didn’t have experience, diminished my anxiety—a little.

2: Is the target population gender and gender identity inclusive? When I called the clinic to make an appointment, the receptionist sounded surprised to hear a man’s voice ask for a pelvic exam. And as I walked into the clinic, I had to ignore that women was the only word on the sign. The door closed behind me, and I kept my head down as I approached the front desk. I wasn’t sure how people would react to seeing a man in a waiting room full of women. I was relieved that the front desk staff greeted me with a smile and treated me like any other patient.

3: Gynecological clinical encounters with trans men. Transgender patients’ positive experiences in health care settings increase the likelihood of their remaining compliant with recommendations, including for screenings. If you’re a clinician or a staff member, the upshot here is that patients’ first encounters could be their last if they feel terrible about what happened to them there. So, the first time a trans man patient has a Pap test, it is important to talk with him about the procedure, including speculum use, swab insertion, and total time it typically takes to complete a physical examination. Approaching patients using a trauma-informed care model can help alleviate transgender men’s anxieties about having their body parts examined and their experience of dysphoria or discomfort.^9,10

As I walked into the clinic, I had to ignore that “women” was the only word on the sign. I kept my head down as I approached the front desk. 

Although I went to my appointment alone, I accompanied a transgender male friend to his and joined him in the exam room. While my friend was still fully clothed, the clinician reviewed his health history. She informed him that if he had discomfort with any of the language she used, he should let her know his preferred terms. Trans men might be uncomfortable with clinically accurate terminology associated with body parts, so when patients prefer different language, clinicians should mirror their language.

Testosterone causes atrophy and dryness of vaginal tissue⁶; for trans men or cisgender women who do not engage in penetrative vaginal sex, a speculum can be especially uncomfortable. My friend was extremely anxious about speculum insertion, due to never having had penetrative sex, so this particular clinician did well to assure him that she would use an appropriately sized speculum for his anatomy. Pediatric-sized speculums, however, are not always helpful, and over lubrication should be avoided.¹⁰ The clinician continued to communicate each step she would take and described what my friend might feel. She then asked him to disrobe from his waist down. Upon completing the exam, she left the room to allow him to put his clothes back on and later returned to answer his questions. This was a positive encounter for my friend and also for me as an observer. This clinician became a trusted caregiver in our community of trans men, and we all began supporting each other in making and attending appointments.

4: Gendering and body parts. Another barrier to care that transgender men tend to experience, if insured, is receiving notice of denial of claims coverage by an insurer. Clinicians can help prevent this occurrence with clear billing communication. After an appointment, for example, a clinician should note the patient’s gender in his health record and notify stakeholders that this might be different than what is on his insurance card. If gender markers, like pronouns or names, are mismatched for a gender-linked procedure, like a Pap test, or gender-linked body parts, like a cervix, it’s helpful to trans men patients when clinicians explain to the billing department the organ-specific services rendered. Taking these steps might decrease the number of insurance claims that a trans man patient is denied.

After my clinician determined that a hysterectomy would be the best treatment for my symptoms and concerns, I informed her that all of my documentation—including driver’s license, birth certificate, and insurance card—affirmed my identity as a man. She stated that she would note specific organs present in my health record and submit forms for precertification to my insurance company. Although my procedure was precertified, 4 months later a postpayment audit flagged the claim due to my being a man, prompting my insurer to request a refund. My clinician helped me appeal by writing a letter noting the medical necessity of the service she provided to me, and the appeal was eventually approved. In my case, the clinician advocating for me increased my trust and desire to return for future care.

5: Inadequate lab results. Inadequate tests or samples are more common among transgender male than cisgender female patients, requiring return office visits and repeat screening.¹¹ Often, the lab notes list “inadequate sample,” “atrophy,” or “dysplasia” as a reason for abnormal or inconclusive results. Not wanting to undergo another exam, a trans man patient receiving such results might not return to a clinic but might remain concerned about the results. In order to decrease the odds of an inadequate test, clinicians should inform the labs they use that a patient on testosterone (which causes thinning of vaginal tissue) had a cervical swab and also note whether the patient is amenorrheic.¹⁰ Taking these steps can decrease the chance of abnormal results, confusion, error, or sample disposal by the lab. For example, the tissue sample taken after my hysterectomy came back with a note about cervical dysplasia, but I didn’t find this alarming because my clinician explained that my long-term testosterone use caused cervical epithelial atrophy, which can mimic dysplasia.¹¹

6: Sex practice diversity and risk awareness. Both transgender men patients and clinicians can be misinformed about screening guidelines and risks. Some trans men lack not only understanding of risk factors for HPV but also general gynecological knowledge. Some clinicians might assume that trans men are less likely to be at risk for HPV because they might also assume that trans men don’t have penile/vaginal penetrative sex. This assumption is wrong. There are a wide range of sexual practices in which trans men might be interested, including penetrative vaginal, anal, or oral sex with partners who have penises that produce sperm. Minority stress¹² due to gender-related discrimination and victimization has a negative impact on health; alcohol use, a history of psychosocial distress, and a history of sex with men only are risk factors for sexually transmitted infections in trans men.¹³

Anyone With a Cervix

Transgender men need to see themselves reflected in data, research, and cervical cancer screening guidelines published in authoritative, reliable sources. When conducting research for this article, I noticed that many sourcescontinued to use anatomical words and pronouns intended to apply narrowly to cisgender women only.^14,15,16,17 It is important to include trans men in cervical cancer screening recommendation language, for example, by stating clearly that screening is for women, transgender men, or anyone with a cervix.

Patients who identify as trans men find it acceptable and preferable to test for HPV with self-collected vaginal swabs.^18,19 Clinicians should offer and provide self-collection swabs as an option to trans men patients, along with education about risks and benefits of HPV vaccination. Clinicians should also offer other forms of screening, such as urine tests for sexually transmitted infections, to increase the likelihood that trans men patients follow screening guidelines while being spared the discomfort of a pelvic exam. The more frequently trans men have positive experiences in gynecological health care settings when seeking routine screening, the more likely they will be to practice regular screening and illness prevention. While I no longer need pelvic exams, I still visit my clinician’s office for hormone therapy monitoring and other health care because I have established trust and had positive clinical encounters. Everyone deserves equality in enjoying this level of quality and trust in their health care.