What Gynecologists Need to Know About Caring for Transgender Patients

A good relationship starts with sensitivity to patients' fears

Transgender men (TM) have unique healthcare needs that can be addressed only by a gynecologist. Yet multiple factors prevent many from seeking the care they need. However, gynecologists have a variety of tools at their disposal to help these patients feel welcome and help them relax , says Cleveland Clinic’s Cecile Unger, MD, MPH, a gynecologic surgeon at Cleveland Clinic’s Center for LGBT Care.

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“It is important to become educated about and comfortable with this group’s health needs and subtleties. It starts with understanding the patient’s gender dysphoria associated with the gynecologist visit and exam,” she explains.

Why TM may delay seeking gynecologic care

 TM are persons born female (“female-assigned”), who identify as men. Because they have female organs, they need the same care that all women do for general and specific gynecologic issues. Additionally, some seek hysterectomy for gender transition or request fertility counseling.

But there are multiple reasons why many TM avoid seeking this care.

“If they are not having vaginal sex, they may think their health risks are low. Those who have achieved amenorrhea on testosterone may think gynecologic care in not needed,” says Dr. Unger, citing two misunderstandings.

But unsatisfactory experiences and bad memories are the primary reasons TM skip gynecological care. Clinician insensitivity and hostility account for nearly 30 percent reporting feeling discriminated against, Dr. Unger reports. Additionally, the routine examination can be painful, trigger traumatic sexual memories and reinforce the distress caused by the incongruity between self-identified gender and birth sex.

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Steps to make TM more comfortable

Dr. Unger suggests making TM patients feel welcome by ensuring all have correct identifiers in their medical record and instructing office staff in the proper use of pronouns.

“Make your décor gender nonspecific, and set up unisex restrooms,” she suggests.

A nondiscrimination policy should be prominently displayed (the American Medical Association offers wording). Educational and marketing materials on trans health topics with affirmative imagery and content will be noticed and appreciated, she adds.

For the exam itself, Dr. Unger recommends offering anti-anxiety medication, if the patient displays severe anxiety about the visit. Pre-examination application of topical lidocaine to the vaginal introitus can be used to help reduce pain.

“Do not make assumptions about sexual orientation and practices, but be sure to explain whether the exam is being done for screening or diagnosis,” she says. “Remember that many will have significant dryness and limited or no vaginal penetration, so use the smallest speculum possible and lubricate copiously. Start the exam with a single digit, open the speculum as little as needed and remove it carefully.”

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Cervical cancer screening

There is no evidence that high doses of androgens cause endometrial or cervical cancer. However, the rate of unsatisfactory Pap smears is higher in TM than in women.

“This may be due to testosterone therapy, but we are not sure,” says Dr. Unger. “However, you should prepare patients for the possibility that a follow-up visit and repeat Pap may be necessary.”

For more pointers and information on managing abnormal bleeding in patients on testosterone, see Dr. Unger’s article in the June 2017 issue of OBG Management.

Also see Dr. Unger’s Consult QD article, “Hormone Therapy and Contraceptive Surgery in Transgender Men.”