Cervical cancer screening information for trans men

I kind of put off getting a Pap test. And my family doctor told me that, as long as I’m not sleeping with men, I don’t need it. And I knew he wasn’t right. But I kind of pretended I didn’t know that so that I didn’t have to go. I put it off for eight years. And just when I got on hormones, the endocrinologist looked at me and said, “This isn’t acceptable.” Like, “You need to have one at this point.” Rhys

All trans men age 21 and older who are or have ever been sexually active and who have a cervix need to be screened with a Pap test every three years.

Trans men with cervices who become sexually active after age 19 should have their first Pap test within three years of first becoming sexually active. For example, if a person becomes sexually active at the age of 23, he can wait until age 26 to have his first Pap test.

Sexual activity includes any genital skin-to-skin contact, including oral sex, digital sex, vaginal or anal sex and sex with toys.

Cervical screening and bottom surgery for trans men

Many trans men have had a hysterectomy (and/or oophorectomy). While there are currently no established recommendations for cervical cancer screening for trans men who have had bottom surgery, these surgeries can affect screening recommendations:

• If a trans man has had a complete hysterectomy that included removing the cervix, AND he has no history of cancerous or precancerous cervical cells, then he will not need regular Pap tests.
• If a trans man has had a hysterectomy that left his cervix partially or completely intact, then he will need regular Pap tests.
• If a trans man has had a complete hysterectomy including removal of the cervix, AND also has a history of cervical cancer, precancerous conditions, HPV infection or immune suppression, he may need to have vaginal vault or cuff smears until he has three documented normal tests in a row.
• Trans men who have had a colpectomy (removal of the vagina) or colpocleisis (closure of the vagina) as part of bottom surgery such as hysterectomy or metoidioplasty, cannot have a Pap test.

Tips for providing Pap tests to trans men

Intimate procedures that examine or expose the genitals can be particularly challenging or uncomfortable for trans men and can trigger or worsen gender dysphoria. Here are some things that you as a healthcare provider can do to make the experience easier:

Split the exam into two parts or even two appointments. You can conduct the interview portion of the exam first, or even as a separate session.

Encourage your client to keep his street clothes on for the interview portion of the exam and to change afterwards. People tend to feel more comfortable and empowered in their own clothing rather than a paper gown.  

Go slowly. Understand that it may take some trans men several appointments and meetings with you to feel comfortable enough to have a Pap test. If a client leaves without having the test, encourage them to come back and consider the visit a step toward screening as opposed to a failure to be screened. 

Let your client know they can bring a friend or an advocate to the exam. Many clients appreciate having someone next to them to hold hands or to provide distraction techniques. 

Don’t assume anything about your client’s sexual orientation or the type of sexual activity he engages in. It’s important to have frank and open discussions about sex and birth control. Some trans men may believe that taking testosterone is an effective form of birth control. It isn’t. You might ask:

• Do you have a sexual partner or partners?
• What are the genders of your partners? Are they also trans?
• Is there a possibility that any of your partners could get you pregnant? If so, are you using birth control? (Do not discount the possibility that a trans man may want to or be planning to get pregnant.)

Use the right words. During the interview, ask your client about preferred gender pronouns and words to describe body parts.  

• Some trans men may find terms like “vagina” and “labia” very disconcerting, and may prefer terms like “front hole” instead. Even if such terms feel unprofessional, they should be respected. 
• Vague terms, such as “external genitals” or “internal part of the exam” may also be preferred. Choose “healthy” or “normal for you” over “normal.”  
• Similarly, many trans men are uncomfortable with references to menstruation and prefer the term “bleeding” or “monthly bleeding.” Remember that some trans men do not menstruate and that these questions may not apply to them and can be uncomfortable.

Gauge comfort with the actual exam. Ask if a client has had a Pap test before, or whether he has had had vaginally penetrative/frontal sex. If a client has no experience with penetration, it may be helpful to know this in advance and to suggest that he try penetration at home first using a small toy, fingers or a speculum. This may help make the screening process less confusing or disturbing. Some trans men may be willing to try this, while others will not.

Make sure that your client understands clearly what will happen during the Pap test and pelvic exam. Ask if your client wants to touch or see the speculum, see pictures of what a Pap test will look like, or use a mirror so that he can see the test and his internal structures. Let your client know that the test is relatively short and that you can stop at any time.

Understand that the speculum may have an extra level of discomfort for trans men. Some may feel uncomfortable with penetration and/or that their gender is undermined by using a speculum. It may be helpful to explain why you need to use a speculum.

Ask your client if he would like you to explain what’s happening as you conduct the Pap test and internal exam. Some trans men will appreciate knowing what’s going on at each stage, while others will prefer silence or distracting chat about other subjects.

Use a water-based lubricant and warm the speculum. Lubrication can make Pap tests more comfortable for everyone, but it can be especially helpful for trans men on testosterone, which can make body tissues dryer. It should be noted on the lab requisition that you used a water-based lubricant.

Understand the effects of testosterone. Testosterone can make trans male genitals look different over time. It can cause the clitoris to grow and the cervix may look atrophic. As well, testosterone can cause cervical cell changes and may make a trans man’s Pap test more difficult to read. If your client is on testosterone, note this on the requisition.

Ask only what you need to know. Although you may be curious, it’s important not to make a trans client feel as though he needs to provide an education session or extra details related to being trans (e.g., you don’t need to ask about top surgery during a Pap test). Explain why you need to ask the questions you do (e.g., “I need to ask you whether you’re taking testosterone because it can change the appearance of cervical cells.”).

Related, respect your trans client’s request not to have a medical student observe the appointment.

Mitigate confusion at the lab. Sometimes, laboratories or lab technicians are confused by a Pap test that comes from a person identified as male on their health card. This can lead to samples being discarded. Save time and effort by noting on the requisition that this is a trans man’s sample.

Be aware that it may be more difficult to obtain an adequate sample. This is likely due to client or provider discomfort with the Pap test and the effects of testosterone on vaginal and cervical tissues. To minimize the chance of an inadequate Pap test, you can:

• make your client as comfortable as possible using the suggestions above
• ensure that you take the time to conduct the test thoroughly and properly
• let your client know that trans men tend to have higher rates of inadequate screening that may require follow-up testing
• explore alternatives to repeated Pap testing, such as cytologic reprocessing of inadequate samples or primary human papilloma virus (HPV) DNA screening of the sample