Cervical cancer screening information for trans women
Some, but not all, trans women have “bottom surgery” (vaginoplasty) to create a vagina (also called a neo-vagina). Sometimes, although rarely, vaginoplasty also includes the creation of a cervix (also called a neo-cervix).
We don’t know enough about screening for trans women and cancer in the neo-cervix or neo-vagina. According to the evidence available, trans women should be screened for cervical cancer as follows:
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Trans women who have not had a vaginoplasty |
Do not need to be screened. Note that some trans women may have had bottom surgery that consists of orchiectomy without vaginoplasty. |
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Trans women who have had vaginoplasty without the creation of a neo-cervix |
Physicians should conduct a visual inspection of the neo-vagina for any abnormalities, at regular intervals as determined by you and your client. Trans women with a history of genital warts, HPV infections or a suppressed immune system are at higher risk of cancer. For these women, a test similar to a Pap test, called a vault or cuff smear, may be appropriate at intervals determined by you and your client. The effectiveness and accuracy of vault/cuff smears, however, has not yet been clearly established. |
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Trans women age 21-70 who have had bottom surgery to create a neo-cervix and who are sexually active |
Should receive a Pap test every three years. Sexual activity includes any genital skin-to-skin contact, including oral sex, digital sex, vaginal or anal sex, and sex with toys. Trans women with a neo-cervix who become sexually active after age 21 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, she can wait until age 26 to have her first Pap test. |
Tips for providing Pap tests and vault or cuff smears to trans women
Trans women who have had vaginoplasty will likely have had several internal and external examinations of their pelvic organs. It’s important, however, not to assume that your client is comfortable with internal exams or familiar with Pap tests or vault or cuff smears.
Ask:
- about your client’s comfort levels before and during the procedure
- whether she’s had a previous Pap test or internal exam
- if she has any questions or concerns about the Pap test or vault/cuff smear
- if she would like to see or touch the speculum beforehand
- if she’d like you to tell her what you’re doing throughout the procedure
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 a post-operative trans women, who may still be healing or sore from surgery, who may have scar tissue, or whose neo-vagina is narrow. Note on the lab requisition that you used a water-based lubricant.
Ask only what you need to know. Although you may be curious, it’s important not to make a trans client feel as though she needs to provide an education session or extra details related to being trans (e.g., you don’t need to ask about breast enhancement surgery or hormones during a Pap test). Explain why you need to ask the questions you do (e.g., “Do you know whether your vaginoplasty included creating a cervix?”).
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. It can save a lot of time and effort to note on the requisition that this is a trans woman’s sample.
Be aware that vault or cuff smears have not been shown to be as accurate as Pap tests in detecting cervical cancer.
Be aware of barriers to screening posed by sex designation on health cards. For example, Ontario Cervical Screening Program (OCSP) currently sends screening results and reminders to people living in Ontario with a female/F designation on their health card.
- Trans women with a male/M designation on their health card currently do not receive correspondence from the OCSP. This can present a barrier to cervical screening for trans women who may have had a vaginoplasty to create a cervix but who have not changed the designation on their health card.
- Conversely, trans women with a female/F designation on their health card who have not undergone bottom surgery may receive correspondence from the OCSP, which can be humorous at best and confusing or offensive at worst. Make sure that you and your client have discussed clearly her particular needs, if any, for neo-cervical or neo-vaginal screening tests.