Evidence suggests that transgender men carry a similar risk for human papillomavirus (HPV)-derived cervical cancer as cisgender women. Gynecologists play a key role in screening for cervical cancer in men, yet less than half of gynecologists say they are familiar with screening recommendations for transgender patients — an informational chasm that may heighten risks and lead to uneven care for male cervical cancer. Fortunately, more resources and research are becoming available for clinicians to remedy cancer screening inequities and provide inclusive OB/GYN care for the trans community.
Screening for Cervical Cancer in Men
The U.S. Preventive Services Task Force recommends cervical cancer screenings every three years for women between the ages of 21 and 65, without mentioning screening for cervical cancer in men. However, the American College of Obstetricians and Gynecologists (ACOG) states that this same screening regime is also appropriate for trans men with an intact cervix.
Even so, research from the American Journal of Men's Health shows just 56 percent of this patient population receives regular cervical cancer screenings, and 1 in 10 reports never having a Pap smear after transitioning. When screened, transgender men tend to experience higher rates of abnormal results than their cisgender counterparts, reports a 2018 paper in Cytopathology.
Trans men are also 10 times more likely to receive unsatisfactory Pap test results, possibly due to vaginal atrophy and inelasticity from gender-affirming testosterone therapy. This population also waits five times longer than cisgender women for a follow-up screening.
Relatedly, immunization against HPV is currently the best primary prevention of HPV-related cancers, yet vaccination rates among trans men are unknown at this time.
Barriers to Care
Interconnected forces related to patients, healthcare providers and health systems create obstacles to screening for cervical cancer in men. Transgender patients, for example, cite social media, the internet and peers as their chief sources of health information. This reliance may spread misinformation about cancer screenings in this community.
In a 2019 survey published in Transgender Health, most trans male and genderqueer respondents could not state the correct age to start cervical cancer screenings or how often the tests should occur. Some respondents incorrectly believed gender-affirming testosterone therapy or intercourse with a cisgender male partner increased their risk for cervical cancer.
Trusted Provider Relationship
Even today, discrimination and insensitivity in healthcare settings continue to stand as roadblocks to essential preventive care. When asked about their use of sexual health services, including cancer screenings, trans men frequently reported postponing or avoiding care due to prior negative experiences with providers, concerns the provider would not understand their healthcare needs or outright discrimination.
In a 2015 survey by the National Center for Transgender Equality, one-third of respondents reported experiencing at least one negative occurrence in a healthcare setting related to being transgender. Respondents were refused care, experienced verbal harassment or were tasked with educating their providers about appropriate transgender care.
Naturally, such experiences act as a deterrent. LGBTQIA+ individuals who experience discrimination based on their gender expression are over three times more likely to avoid routine Pap smears, reports the Journal of Clinical Nursing.
Conversely, when a trusted provider recommends cancer screening, patients often express a greater willingness to agree to the exam, the Transgender Health survey found. Trusted providers are described as those willing to answer questions and who allow the patient to decide whether to have a Pap smear or not.
However, trust takes time to form. Several visits may be necessary before a trans male feels safe with the provider and the idea of being screened.
A lack of health insurance also stands in the way of routine cervical cancer screening in the trans population. One-quarter of respondents in the 2015 National Transgender Discrimination Survey had experienced insurance coverage obstacles and refusals for routine care. Similarly, insured trans individuals whose medical records correctly indicate their gender as male report being denied coverage of Pap smears because insurers code the exam for cisgender women.
Reframe and Empower
Simple modifications in the exam room, such as nondiscrimination signage and affirming word choices, may break down the psychological barriers to cervical cancer screening. For example, a paper in Qualitative Health Research finds trans men are more willing to have a Pap smear when providers reframe the screening as gender-neutral or masculine. Guidance from the Canadian Cancer Society suggests using gender-neutral terms, such as "cancer screening" rather than "Pap smear" and "genital opening" instead of "vagina."
When striving to create a more inclusive experience, clinicians may wish to start by gently asking trans patients about positive or negative encounters in the past. Because many trans men find speculum insertion and cervical scraping painful, providers may wish to offer more comfortable alternatives, such as using a pediatric speculum, allowing the patient to insert the instrument themselves or employing an HPV swab.
In research comparing screening methods in LGBT Health, more than 90 percent of trans men favored the HPV swab method, describing it as less invasive and less painful than the traditional practice. Similarly, when surveyed, most trans respondents preferred HPV self-sampling, saying that the method triggered less emotional distress and fostered a sense of agency.
Providers Must Seek Out Training for Inclusivity
In a March 2021 committee opinion, Health Care for Transgender and Gender Diverse Individuals, ACOG encourages clinicians to seek out education to address healthcare disparities, both in their individual practices and in the greater healthcare system.
The report provides further guidance for clinicians who wish to educate themselves and their medical teams about appropriate language and the healthcare needs of their transgender patients. A more informed outlook may open the door to improved access to preventive care for this community.
