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Pilot Program Shows Why We Need More Cervical Cancer Screenings for Trans Men


 

A pilot program from RM Partners, 56 Dean Street, and the Gender Identity Clinic (part of the Tavistock and Portman NHS Foundation Trust), all in London, is highlighting the importance of providing trans men and nonbinary people with cervical cancer screening that centers around their personal preferences and biological needs.



Cervical cancer is the fifth most common cancer in the world.1 In the United States, it is estimated that around 14,480 new cases of cervical cancer will be diagnosed by the end of 2021 and around 4,290 women will die from cervical cancer.1


The only way to prevent cervical cancer is through regular monitoring, which includes cervical examinations. In America, screening is recommended every three years for people with a cervix between the ages of 21 and 29, and every three to five years for those between age 30 and 65. In the U.K., where the pilot took place, cervical screening does not start until the age of 25.


 How to Prevent Cervical Cancer


Reproductive Healthcare for All

Trans men and nonbinary people who have not had surgery to remove their cervix still need to have cervical cancer smears at the same frequency as cis women. Unfortunately, trans men and nonbinary people often face barriers to accessing reproductive healthcare, including essential preventive services like cancer screenings. 


“Trans people experience myriad health inequalities both with regard to access to gender-affirming services, but also related to their general health care,” Alison May Berner, MBBS, MRCP, the lead author of the study, tells Verywell. Berner is a specialty trainee and clinical research fellow in medical oncology at Barts Cancer Institute in London, and a specialist registrar with the Gender Identity Clinic. 



Berner says that it was important that the project involved specific organizations (including Jo’s Cervical Cancer Trust and specialist trans health clinic 56T) because it allowed them to “really tailor it to the best of our ability to help trans people engage. It’s quite hard to feel that a service is for you if you don’t see yourself reflected.”2



 FOLX Is the First Digital Healthcare Platform for Queer and Trans Community

Barriers to Care

Prior to the pilot screening program, Berner was the lead author of a study on the attitudes of transgender men and non-binary people toward cervical screening in the UK.1



Trans people experience myriad health inequalities both with regard to access to gender-affirming services but also related to their general health care.

— ALISON MAY BERNER, MBBS, MRCP

The study asked 137 transgender men and non-binary people a series of questions about how they felt about cervical screening in the U.K. The results showed that:


64% of the respondents stated that they would prefer to attend cervical screenings at a trans-specific health clinic

7% said that they would rather be screened by their general practitioner

Only 35% of participants felt they had enough information about cervical screening to make an informed decision.1 


Genital dysphoria was reported by 82% of the participants. Only 18% of the group said that they felt comfortable having their genitals touched, and 13% were not. About two-thirds said that they were comfortable with genital touching “sometimes” or that it depended on the situation. There was variation in comfort both within the context of healthcare and in sexual situations.1


Confronting Bias

Many respondents were worried about experiencing prejudice from doctors and healthcare staff—something that Jasper Williams, a trans man, has experienced firsthand. “The receptionist told me I had a ‘man's name’ on arrival, so it wasn’t a great start,” he tells Verywell.


Williams also discussed the access barriers that many people face. For example, when you change your gender from female to male on your official documents in the U.K., you stop receiving invitations for cervical cancer screenings. In addition to being harmful, Williams says that the change places added stress on patients because “it feels like the total responsibility of yourself to suddenly think about your cervix.”


Trans Health Beyond Transition

The tailored screening program initially launched in October 2019 with a 10-day social media campaign on six platforms that reached about 40,000 people. However, only nine people were screened before the clinic had to close in March 2020 because of COVID-19 restrictions.2

People assume that this population’s healthcare-related needs are solely related to transition. That’s not true.

— ALISON MAY BERNER, MBBS, MRCP

Berner said that the initial feedback from the pilot program suggested that trans-specific cervical screening is beneficial and could help ensure that cervical cancer does not go undetected in the trans and nonbinary population.


“People assume that this population’s healthcare-related needs are solely related to transition. That’s not true,” says Berner. “Trans and nonbinary people are at risk of HPV infection and cervical cancer if they continue to retain a cervix, and they stand to benefit from programs designed specifically for them.”


While we know the scale of cervical cancer in cis women, it’s more difficult to know how much it has impacted trans men and nonbinary people, as cancer estimates for trans people usually come from the Netherlands.


However, in the Netherlands, you could not change your gender on your official documents from female to male without a hysterectomy until 2014, meaning that there are no quantifiable cervical cancer statistics for trans men yet.3


Transphobia in Healthcare

Many nonbinary people and trans men are not out to their medical team for fear of transphobia or that they’ll be denied medical treatment. These fears are not unfounded—the results of TransActual's 2021 Trans Lives Survey showed that 71% of trans men and 83% of nonbinary people in the U.K. said that they had been discriminated against when accessing healthcare services.4


Artie Carden, who is nonbinary, tells Verywell that they are “personally not out to any staff due to safety concerns but I am reasonably visibly queer.” Carden says that “due to having numerous conditions which have me in and out of doctors’ offices a lot and different doctors, I just don’t feel safe enough to be out in case of further medical neglect.”



Educating Providers

While it’s far from an excuse, part of the problem might be a lack of education among healthcare providers. In Dr. Berner’s study on attitudes about cervical cancer screening, most of the participants (130 out of 133) felt that more training on LGBTQ+ issues—including terminology and lived experience—was needed for healthcare professionals.1  


Half of the participants also expressed an interest in having information that was focused on trans men and nonbinary people within non-specialist cervical screening services. 


 Simulation Will Help Train Doctors in Gender-Affirming Care

It’s also down to how confident healthcare professionals feel about treating trans patients. In a 2017 study in Transgender Health, even though 97% of respondents agreed that transgender medical issues were relevant to their practice, only 45% had prior education about the care of transgender patients.5


A survey of obstetrics and gynecology providers published in The Journal of Women’s Health in 2015 found that of the 141 respondents, 80% had received no training or education on how to care for transgender patients.


Of the same cohort, 88.7% said that they were willing to perform a cervical smear on a trans man. Only 35.3% were comfortable caring for trans women and 29% for trans men.6


Normalizing Care

The clinic reopened in July 2020 and 35 trans men and nonbinary people received tailored cervical screening in the clinic between July 2020 and February 2021. The organizers received feedback surveys from 20 of the participants, which showed that:2


Most respondents (12 out of 20) said that if the service had not been available, they would not have sought out a cervical screening.

Of the 20 respondents, 9 said that if their own doctor provided a trans-specific screening, they would get it.

Nathaniel*, received a cervical smear examination at 56T (where the pilot was based) through the weekly trans health clinic. He had previously had a negative cervical smear experience, which he says was “so painful we couldn’t carry on.”


The next time around, he also feared transphobia. “For all I knew, the nurse performing the smear test might be actively transphobic and might actually cause me extra pain on purpose. And that’s all on top of the fact that I’d have to get half-naked and present my genitals to a stranger.”


Nathaniel says that “knowing that the clinic was trans-inclusive was a big relief,” and that “everyone I spoke to there was just lovely and very understanding, including the nurse who performed the test.”


It was also a huge relief to be met with acceptance. He says the nurse “was very sweet and clearly had sympathy for the fact that the experience was extra hard for me because of my gender identity, and I found that very supportive.”


Berner thinks that the pilot normalizes access to gynecological health for trans men and nonbinary people by making it “just another healthcare check. You have a level of visibility and normalization you can’t put a price on.”

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