How to Approach Cervical Screening for Transmen and Non-Binary Individuals – for Health Professionals

Considerations:

There are several things to consider when a transman or non binary, assigned female at birth individual presents for routine cervical screening. It is important to remember that cervical screening in a transman or non-binary individual can cause significant distress and further exacerbate their dysphoria. Engaging with a health practitioner to discuss this and have a vaginal examination can be difficult and very confronting especially when there is dysphoria around their genitals.

Transgender Men and/or Non-Binary people assigned female at birth, who have not had surgery to remove the cervix, are recommended to undertake cervical screening with the same frequency as cisgender women, but evidence suggests that they have lower odds of lifetime and up-to-date cervical screening uptake compared with the cis gender community.

There is no increased risk of Cervical Cancer from Testosterone therapy, but it can make it harder to obtain an adequate sample due to discomfort from vaginal atrophy/dysphoria.

Screening invitations and eligibility:

·      Trans men and non-binary people assigned female at birth who have had a total hysterectomy to remove their cervix do not need cervical screening.

·      Trans men and non-binary people assigned female at birth who still have a cervix should have cervical screening to help prevent cervical cancer.

·      Trans women and non-binary people who are registered as female but assigned male at birth do not need cervical screening as they do not have a cervix

Impact of Gender Marker:

·      Trans men and non-binary people assigned female at birth who still have a cervix but are registered with the GP as male will not be invited automatically for smear tests.

·      Trans men, or non-binary individuals assigned female at birth, registered with the GP as female, will receive automatic invitations for cervical screening: every 3 years at ages 25 to 49, then every 5 years at ages 50 to 64

Whilst both Public Health England and NHS England recognise that Transgender Men and/or Non-Binary people, with a cervix, require cervical screening, the guidance document available leaves this responsibility up to the GP Practice or Health Care team to organise and ensure fail safe systems are in place.

It is important to remember that a trans or non binary individual may not have disclosed the assigned sex at birth to their GP practice. Therefore, there may be patients who are not aware they are eligible for screening. We recommend that practices aim to increase awareness in this cohort of patients by adding trans inclusive information about screening to websites and social media. Patient-facing staff should be made aware that male-presenting patients may be eligible for cervical screening to avoid uncomfortable situations for individuals booking appointments.

We suggest that GP practices should consider their recall systems for those patients registered as male who are eligible for cervical screening, to ensure opportunities for screening are not missed.

Reasonable Adjustments to improve Cervical Screening uptake:

Environment:

·      Offering the opportunity for a discussion with a healthcare professional in advance to cover any concerns the patient may have

·      Offering patients a double appointment for a smear test to allow adequate time if they are feeling anxious or an appointment at the beginning or end of clinic to avoid long waits

·      Ensuring correct use of pronouns and asking the patient if they have any preferred language/terms when referring to body parts

·      Ensure correct name appears on waiting room screen

·      Having a range of speculum sizes available and considering the opportunity for the patient to try self-insertion at home beforehand

·      Asking if the patient would like to bring a friend with them to the appointment

·      Use of vaginal oestrogens prior to a smear test to reduce pain and dryness associated with vaginal atrophy

Vaginal Estrogens:

Testosterone changes the vaginal epithelium in a similar way to post-menopausal changes in cis gender women. The proliferation of the epithelial cells slows and becomes thinner and more fragile causing bleeding or vaginal discharge. As a result, vaginal examinations can be distressing not just due to dysphoria but also due to discomfort and pain. Consideration can be given to using vaginal estrogens to treat the atrophy before a full examination of the vaginal vault is possible.

The recommendations are not limited to the below. If atrophy is suspected and the individual is unable to tolerate a full examination, we would suggest treatment for 4-6 weeks before another attempt at vaginal examination is made. In some severe cases it may necessitate more frequent and prolonged application of topical Estradiol than in postmenopausal females.

·      Vagifem/Vagirux: 10mcg tablet daily for 2 weeks then 1 tablet twice per week (if still symptomatic at 2 weeks it would be appropriate to continue with application daily for 4-6 weeks).

·      Ovestin cream 0.1%: 1 application per day for 2-4 weeks then reduction based on symptoms down to a maintenance dose of one application twice per week.

Occasionally a combination of a vaginal preparation and a vulval preparation are also required along with vaginal moisturisers such as coconut oil.

Other Services:

Some areas may have trans+ specific clinics available who can offer cervical screening in a welcoming space which may be less daunting for patients. Please be aware of the Trans & Non-Binary Sexual Health Clinic here in Leeds (or your nearest centre) which is on the 3rd Monday of every month, from 4-6 pm for HIV and STI testing, Cervical smear tests, Hepatitis and HPV vaccines, Contraception, Pregnancy tests and PrEP. For more details they can contact leeds@mesmac.co.uk or phone 0113 244420922.

Many sexual health clinics also offer cervical screening for trans and non-binary individuals. In the future it may be that there is greater up take of cervical screening from self-taken samples however there are concerns over the lack of longer-term evidence to support this.

More information:

There is some great information on the ‘Outpatients’ website (formerly Live through this) with specific content for patients:

·      OUTpatients - LGBTIQ+ Cancer Charity

·      My Cervix My Service - OUTpatients

·      Cervical screening for trans men and/or non-binary people | Jo's Cervical Cancer Trust (jostrust.org.uk)

Summary

In conclusion we recommend that GP practices should:

·      Follow an individualised approach to cervical screening with an understanding of the personal, societal, and systematic barriers at play

·      Identify cohorts of patients eligible for cervical screening but not registered female and ensure robust recall systems are in place to invite them for screening

·      Create a welcoming and non-judgemental environment for patients to attend for screening and consider reasonable adjustments including the offer of topical oestrogens

·      Raise awareness of cervical screening amongst their patient population for trans and non-binary cohorts