We think this may be in part due to decreased rates of cervical cancer screening among LGBTQ people with cervixes.
Medical provider bias, non-affirming practices and language, and a lack of a trauma-informed approach probably contribute to lower rates of screening. This is doubly harmful to LGBTQ+ populations because cervical cancer screening (a Pap test with or without HPV DNA testing) saves lives. Prior to the invention of the Pap test, cervical cancer was a top killer of people with cervixes, now it isn’t even in the top 10 list! This is a screening test with fairly good statistics – low false positive and false negative rates, and it is considered “minimally invasive” in the medical world….
“Minimally invasive” is a subjective term, and, as far as I am concerned, an inadequate – and potentially harmful – description of a pelvic exam to me.
It is woefully inadequate when you layer on any intersectionality with having a cervix – like gender diversity or a history of trauma. This inadequacy can make screening difficult for the patient, add to or create trauma, and delay identification of problems that can be treated if found early. Having performed hundreds of pelvic exams and having received several myself, I have some insights on how to improve cervical cancer screening for LGBTQ people:
First, lots of conversations and information sharing!!!
Ideally, these conversations happen on a different day (and before) your scheduled screening to give you time to think about it without feeling pressured!
Individualized Shared Decision Making:
prior to any exam, with all of everyone’s clothes on, have a conversation about screening.
- What are the risks of not screening?
- What are the benefits of not screening?
- What are the risks of screening?
- What are the benefits of screening?
This conversation should be specific to you by including your overall health, sexual practices, and HPV vaccination status.
Informed consent:
prior to any exam, with all of everyone’s clothes on, have a conversation about the screening options and what to expect.
What are the options for *how* to screen for cervical cancer?
- Self-swab for HPV
- Provider collected swab for HPV
- Provider collected cervical cell sampling for cell changes
- What is a pelvic exam like?
- What are the steps?
- Who will be in the exam room?
- What is inappropriate during an exam?
Did you catch that self-swab option?
Self-swabs for HPV are not as standardized or as thorough as a provider collected HPV/cytology sample, but they do allow you to avoid a pelvic exam and may help reduce your risk of cervical cancer! They are not currently recommended as a national standard of care in screening, but we see them as preferable to not screening at all. When self collecting a sample, there is a risk of not being able to collect enough cells for a valid test.
Preparing for the screening procedure:
Preparing your body:
If you menstruate, schedule (as best you can) your test for a time when you are NOT having your period
If you are going to have a test in the next two days AVOID placing things in the internal genitals including douches, tampons, genital receptive sexual practices, lubes, medications, etc.
If you have been on testosterone for a few years, you may need to treat your cervix with estrogen/progesterone prior to screening.
- This is temporary and low dose and will not affect your transition
- It encourages the cervix to open allowing the cells needed for screening to be more accessible, which decreases the likelihood of inadequate sampling
Preparing your mind/spirit:
Pelvic exams can be traumatic and/or can retraumatize, consider ways you can minimize this:
- Having a support person or advocate
- Taking an anti-anxiety medication prior to the procedure
- Hopefully, having a provider you trust
- who will help develop an individualized approach
- who you know will STOP when you say so at any point
- who respects your gender identity and uses affirming language during your procedure
When I did pelvic exams, including for cervical cancer screening, I offered alternative screening methods (like the self swab,) anxiety medication, reviewed what to expect, confirmed affirming language, and negotiated narration of the procedure.
Narration of the procedure should be individualized – some people find it very helpful to have every step explained prior to it happening, some people would rather you explain things only if you have to deviate from the previously explained procedure. If your provider isn’t offering you these things, consider asking why or finding someone else.
PSA: Medical exams without consent are assault.
If you have experienced sexual assault, whether in a medical setting or not, and would like support, RAINN is a national organization with a free and confidential telephone hotline, chat service, and mobile app.
Reviewed July, 2021.
