Fenway Study: Inadequate Pap Tests in Transgender Men


pap_smBy: Lauren Walleser/ TRT Assistant Editor—

BOSTON, Mass. — A recent study published in the Journal of General Internal Medicine (JGIM) finds that female to male (FTM) transgender patients had over 10 times higher odds of having an inadequate Papanicolaou (Pap) test compared with female patients.

Fenway Health’s Director of Women’s Health Jennifer Potter and colleagues from Fenway, Harvard Medical School and the Johns Hopkins School of Public Health conducted the research.

“We hypothesize that both the physical changes induced by testosterone therapy and provider/patient discomfort with the exam that may interfere with the collection of an adequate sample during the Pap contribute to this trend,” said Ida Bernstein, the study coordinator. “Further research is required to understand this disparity and test these theories.”

According to a Fenway Health press release on the study, cervical cancer can still occur in FTM trans men if they have not undergone complete sex reassignment surgery or wait until later in life to have a complete hysterectomy. National guidelines, therefore, recommend trans men with a cervix receive Pap tests. 

According to a Fenway Health press release on the study, cervical cancer can still occur in FTM trans men if they have not undergone complete sex reassignment surgery or wait until later in life to have a complete hysterectomy. National guidelines, therefore, recommend trans men with a cervix receive Pap tests.

“If a person on the FTM spectrum has not had a total hysterectomy, which includes removal of the cervix, and has ever had skin-to-skin sexual contact with another person, they are at risk of HPV,” said Bernstein. “All people who have had sexual contact with another person are at risk of HPV regardless of the kind of sex they have, even if there’s no penetration or fluid exchange. Some strains of HPV cause changes to the tissues of the cervix that can lead to cancer. Cervical cancer screening is an important part of preventive health for all people who have a cervix.”

The study shows that FTM patients had a prevalence of inadequate samples and were also more likely to have had longer latency to follow-up testing. When asked if negative experiences with healthcare lead trans men to not undergo regular Pap tests, Bernstein spoke to a related study.

“We are interviewing individuals on the FTM spectrum and conducting an online survey open to the FTM community to better understand people’s experiences with and barriers to Pap tests,” Bernstein said. “We have so far found a huge range and diversity of experiences and attitudes towards Pap tests specifically and healthcare in general across our participants. 

Negative interactions with healthcare providers and/or other clinic staff are one factor that can lead FTM patients to be reluctant to seek care or even avoid care altogether. While the need for gender-affirming and competent care for FTM patients is clear, the work to understand these and other barriers is ongoing.”—Bernstein

Mason Dunn, executive director of the Massachusetts Transgender Political Coalition, also shared his thoughts on trans experiences with healthcare. Negative interactions with healthcare providers and/or other clinic staff are one factor that can lead FTM patients to be reluctant to seek care or even avoid care altogether. While the need for gender-affirming and competent care for FTM patients is clear, the work to understand these and other barriers is ongoing.”

“The impact of negative experiences in healthcare for trans people are far-reaching and deeply concerning,” said Dunn. “When doctors fail to provide compassionate or understanding care, many trans people are less likely to seek out necessary or preventative medical care. In one study—“Injustice at Every Turn”—50 percent of surveyed trans people reported having to teach their medical care providers about trans identities. This lack of information takes significant time to remedy and sometimes leads to frustrating interactions with healthcare professionals. If a trans person is required to explain the very foundation of their identity at every appointment, they may be less likely to seek out care when they need it.”

Bernstein said more research is needed to understand the changes on the cervix induced by testosterone as well as patient/provider discomfort with Pap tests. Both Bernstein and Dunn agreed, in the meantime, that it is important for healthcare providers to make these tests and exams more comfortable.

“The diversity of comfort with and preferences for the Pap that we are observing across people on the FTM spectrum suggests that providing patients with as many options as possible to customize the Pap to fit their personal needs may be an effective strategy, including options related to how the Pap is physically performed as well as interactions between the patient and provider,” said Bernstein. “Avoiding assumptions when working with this diverse population is of paramount importance. We need to be mindful of creating health settings that are welcoming and inclusive of all gender identities. Work to develop interventions to address patient and provider barriers to accessing and providing this important preventive care, respectively, is necessary and ongoing.”

Dunn echoed those sentiments.

“It’s important for providers to respect identities that come to them seeking care,” Dunn said. “Respecting pronouns, names and gender identities is pivotal to providing compassionate healthcare. Additionally, providers should have open communication with those seeking care about what language they would prefer to use in terms of identity, their body and relationships.” 

“Respecting pronouns, names and gender identities is pivotal to providing compassionate healthcare. Additionally, providers should have open communication with those seeking care about what language they would prefer to use in terms of identity, their body and relationships.”—Mason Dunn, MTPC

The research involved a retrospective electronic medical record review of Pap test results from tests performed on 233 FTM and 3,625 female patients at an urban community health center between 2006 and 2012.

Bernstein said Fenway is also developing a brochure on HPV and cervical cancer screening for people on the FTM spectrum and are asking for feedback on this brochure from the FTM community. They are also developing provider trainings using the brochure as an educational tool.

For more information on Fenway Health, visit www.fenwayhealth.org.

 

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