#31: Transmasculine Paps
COMMUNITY VOICE: Kellan Oelkers | HEALTHCARE EXPERTS: Alison Berner BA(Hons), MBBS, MSc, PhD, MRCP; Helene Hedian, MD | COMMUNITY REVIEWER: Fiorenza Piccorelli
SHOW NOTES
A caveat (what else is new?)
The audience
This episode is primarily aimed at transmasc folks navigating cervical cancer screening
However, anyone with a cervix may find this information useful!
The language
We also use anatomic language (like cervix and vagina) in this episode.
Why? Using precise terms helps make medical discussions clearer, safer, and easier to follow in a podcast format like this
In clinic, we recommend all people ask that their providers use whatever terminology they would like to describe their bodies – it need not be anatomic!
Ah, yes – the vocab section of the QHP show notes
Cervix:
The lower part of the uterus that opens into the vagina — this is the part that can be checked for cancer.
Think of it as the “gateway” doctors look at during screening.
Pelvic exam:
A broader exam of reproductive organs for those assigned female at birth.
It may include a pap smear but, depending on what the person needs, can also look at other structures like the uterus and ovaries.
Pap/Pap smear:
A test that uses a brush to collect tissue from the cervix to check for abnormal cells or HPV infection.
It’s the main way we catch problems early before cancer develops.
More on this below!
HPV
Human papillomavirus, a very common virus that can spread through skin-to-skin contact
Certain “high-risk” strains can cause cervical cancer over time (again, more on this below).
Cervical cancer
What even IS it, anyway?
Like all cancers, cervical cancer starts when cells in the cervix grow atypically, or out of control.
Fortunately, it’s really slow growing! When caught early through screening, cervical changes can often be treated before they become cancer.
What causes it?
HPV infection:
Most people get it at some point, and most bodies clear it on their own.
Most people get it at some point, and most bodies clear it on their own.
Certain “high-risk” strains can cause cervical cancer over time.HPV is like glitter – once it’s on your body, it can move around and be hard to get rid of.
And it isn’t only spread through penetrative sex — skin-to-skin or skin-to-toy (or even skin-to-tampon) contact can transmit it.
This is why everyone with a cervix, regardless of sexual behavior, is recommended for screening
Smoking:
How: chemicals in cigarettes can weaken the immune system’s ability to clear HPV and increase the risk of cervical cell changes.
We know, we know – smoking comes up a lot in healthcare settings. But the relationship between this and HPV transmission is very well-established, so worth mentioning here, for real.
Testosterone use?
Research is still limited, but the hormone itself does not appear to directly cause cervical cancer
This is based on expert opinion from our guests!
Other factors: immunosuppression, HIV infection (whether treated or not)
Demystifying the pap smear (Betty Friedan, hold my beer!)
When to screen:
Starting at age 21, every three years; at 30, can switch testing strategies to every five years
This is true of everyone who has a cervix!
The steps
A speculum is placed into the vagina, and is then opened to allow visualization of the cervix
Cells are collected from the cervix with a small brush or spatula.
The collected cells go to a lab to check for abnormal cell structure and to test for the presence of HPV.
The experience
Most of the time, the procedure takes just a few minutes
What you may feel
It may feel uncomfortable or cold, but it shouldn’t be painful at any point in time. (No, seriously.)
There may be some light cramping during or after the procedure, but this is usually short-lived.
The follow-up
If the pap smear comes back abnormal, this may increase screening intervals - from once every three-to-five years to a year later
Certain results require a closer look at the cervix, which is done via a colposcopy. This is a procedure done at your neighborhood queer-friendly GYN’s office, where they may take small samples (biopsies) of the cervix to get a better sense of what’s going on
Why do trans people not like pap smears?
Being trans and getting healthcare:
It is understandably stressful to be in clinic and face the possibility of being called the wrong name or pronouns, or encountering providers unfamiliar with trans health.
And for some, engaging with that part of the body can trigger additional layers of body dysphoria or anxiety
As Kellan points out, an LGBTQ+ clinic can be a way to ensure the environment is as affirming as possible for cervical cancer screening.
Provider knowledge gaps:
Some clinicians are unfamiliar with trans-specific screening guidelines and may not recommend screening to trans people!
Some providers assume transmasc people with a cervix don’t need screening — which isn’t true!
Past trauma or negative experiences:
Previous painful or invalidating healthcare interactions can make it hard to come back.
Worries about being shamed or judged for not having been screened or being late to screening are a big deterrent for many
Lastly, the masculinity of it all:
In some communities, men aren’t always encouraged to take care of themselves
This can be an extra layer for trans guys navigating preventing health including cervical cancer screenings.
Affirming pap smears: a how to
Before the visit
Schedule a visit (a vibe check, if you will)
Primarily to discuss cervical cancer screening, your risk, and what the procedure looks like.
You can also discuss pre-medication, which can include anxiety medications (relevant for some), pain medications and possibly vaginal estrogen cream to help make the procedure more comfortable
Pro-tip from Dr. Hedian: this can be done over video!
Ask for a support friend to join you and let your clinician know they will be coming
During the visit
Ask your provider to narrate what they’re doing and ask them to check in: “Is this okay?”
You don’t have to push through discomfort — stopping or rescheduling is very okay.
Where available, self-swabs for HPV may give you more control and reduce dysphoria.
The present – and future! – of cervical cancer screening
Self-swabbing in clinics:
Clinics are increasingly allowing patients to collect their own samples during an appointment, instead of having a provider do it. Think of it as a “vaginal COVID test” (in Kellan’s own words!)
The test remains accurate but as Kellan points out this gives more control to the patient, reducing discomfort or dysphoria
For some people, this allows them to skip a pelvic exam for a traditional pap smear. But if a self-swab is abnormal, next steps will likely include a pelvic exam to perform a follow-up procedure to better examine the cervix.
At-home HPV kits:
Newly approved by the FDA this past May (!)
Like the self-swabbing in clinic experience, but then you…mail it in!
Not yet rolled out at most clinics, but stay tuned!
Urine HPV
The premise: catches the HPV that may be present on the genitals, particularly if done first-void (AKA first pee of the day)
This is still a newer testing strategy, but initial data is looking promising
And, of course, it’s definitely more comfortable for people by virtue of being less invasive (plus you get to pee standing up)!
TRANSCRIPT
Kellan: And it feels good to be going to a doctor's office where I feel empowered to take care of myself physically, like as an act of self care. And now I find taking care of my sexual health to be very appealing, thanks to the care I received , and thanks to this autonomous self pap smear experience, it's something I'm like really excited about continuing.
[QHP THEME MUSIC STARTS]
Sam: Welcome to Queer Health Pod, a podcast by queer people for queer people about queer health. I'm Sam. I use he/him pronouns, and I am a queer primary care doctor in New York City. The two movies I watched from the Times a hundred movie list were Mad Max Fury Road and a Serious Man, which was not an obvious pairing, but I enjoyed them.
Gaby: I don't understand how you didn't see Brokeback Mountain. I feel suspicious, but she/ her pronouns, and I have the same job title.
Richard: I'm Richard, he him, and same job title just with much more time on the job than these two. And yes, Carol from the New York Times list, which Gaby has yet to allow me to watch since I've committed to watching it with her.
Gaby: And you are listening to Queer Health Pod, Episode 12: Cervical Cancer Screening for Transmasculine People.
[QHP THEME MUSIC ENDS]
Richard: On today's episode, we're gonna talk about what every primary care doctor loves: preventative health screening.
Sam: Are we also gonna talk about how to time Carol so that they kiss at midnight, or is that for a different part of the internet?
Gaby (laughing): That requires actually four episodes and a lot of Tumblr posts, so.
Sam: Is – is Carol the most Christian lesbian movie? A dangling question. However, today we're gonna be talking about cervical cancer and how to prevent it.
Gaby: This episode will focus on the experiences of transmasculine, masc of center and non-binary folks assigned female at birth.
Richard: Our community voice, Kellen, is himself trans identified.
Kellan: My name is Kellan Oelkers. My pronouns are he/him/his and I am a transgender man in my mid late twenties.
Gaby: That being said, my suspicion is that this episode is gonna have resonance for other people who have cervixes and, and I guess the people that I'm really getting at here are cis women, and that's because this episode's gonna cover, first of all, the 101 of cervical cancer. So what it is, how it develops, who's at risk. We're gonna demystify pap smears. We're gonna talk about what they are and how they help prevent cancer. We're gonna acknowledge the barriers to screening. We're gonna talk about dysphoria past experiences with pap smears that have been negative, and then a bunch of other stuff. And we're gonna talk about how to make those experiences that were negative better. What kind of strategies and changes make screening more affirming and more comfortable for transmasculine people? And that includes a new way to screen something called a self-collected swab, which is really exciting. And if that sounds exciting, just know that there's more on what's next. We're gonna talk at the end, about the future of cervical cancer screening and why I am so excited about it.
Richard: Our goal today, as always, is to power share knowledge. We want people to be able to make informed choices about the risks and benefits of getting screened, and if you're getting screened, we wanna provide some ideas about how to make that experience go as smoothly as possible.
Gaby: And one caveat, which is: for the purposes of this episode, we're gonna be using anatomic vocabulary to describe the parts of the body that we're talking about. And I just wanna say that we know that people may use other terms to describe their own body parts, and in my actual clinical practice, I mirror the terms that are used by the people in front of me. The reason we're sticking to anatomic terms here is just to make sure that we're all on the same page about what parts we are talking about.
Sam: Four minutes, 46 seconds into recording and there's our first QHP disclaimer. I hope everyone feels at home. So another QHP classic: an early in the episode definition section. So Gaby, what even is cervical cancer?
Gaby: Cervical cancer happens when the cervix, the lowest part of the uterus that opens into the vaginal canal, starts developing abnormal cells that don't stop growing. A pap smear is a screening test that's been traditionally used to catch these abnormal cells early before they can turn into cancer.
Richard: Cervical cancer as a concept isn't too different from other forms of cancer: lung cancer, pancreatic cancer, they all involve abnormal and uncontrolled cell growth, in particular areas of the body. But every type of cancer has its own risk factors, things that will make it more likely to develop in that area.
Gaby: Kellan, for his part, felt pretty uncertain about what those risks are.
Kellan: To be honest, I feel so uneducated about my own risk for cervical cancer. Anytime I said no to a pap smear, I was thinking in the immediate, not the long term. I was definitely prioritizing immediate comfort or searching to eliminate immediate discomfort, without really thinking of the consequences. I don't know how HPV becomes cervical cancer. Like what are the rates of that happening? I- Lots of follow up questions I have. Does it get worse with age? I don't know.
Sam: If you heard HPV and you were like, HP what? Hang on. We will define that in just a moment.
Gaby: I do wanna name that there's an asymmetry here, that we have a lot more patient education about all of this, meaning cervical cancer screening. For cis straight women, there're scarcely anything on pap smears and cervical cancer for trans men, which is why it's not surprising to me that when you look up the statistics, trans men are about 37% less likely to get screened for cervical cancer.
Richard: All of which is to say Kellan's questions deserve an answer. So we turn to our first health expert, Dr. Alison Berner.
Dr. Berner: So my name's Alison Berner. My pronouns are she and her. I'm a medical oncologist, which means I treat cancer for a living, but I'm also a gender-affirming care doctor. And I lead something called the UK Cancer and Transition Service, which is a service that aims to integrate cancer care and gender affirming care for trans folk.
Sam: Here was her answer to Kellan's first question about how HPV impacts cervical cancer risk.
Dr. Berner: So HPV is human papillomavirus, so actually it's a family of viruses, about a hundred of them. They live on body surfaces. So you can get HPV on your skin, you can get it in your hands. That's what causes hand warts. Some, members of the family called genital warts and some members of the family, cause cervical cancer or cervical precancers. Actually HPV is related to other cancers too. We talk a lot about cervix cancer, but actually it's the cause of anal cancers, oral cancers, Cancers on the vulva and vagina and penis. But HPV essentially has a way of hacking the way that cells work. It's really good at growing and multiplying. That's what viruses like to do.
Sam: So HPV hacks cells to make them grow more, keeping the gas pedal on until the cells move from normal to abnormal precancerous, and then to full on cancer cells.
Richard: But who is actually at risk for getting HPV in their cervix?
Dr. Berner: So I mentioned that HPV is on body surfaces, which means it travels when those skin services contact each other. And so when we talk about HPV in the cervix, it needs to get into the vaginal canal or what you call the part of that body, depending on how you refer to your own anatomy. And so it can get there via anything moving into that space. So it can be a part of someone else's body, it can be a part of your own body. It could be, for example, other things that you put there. So toys or tampons. And we don't know a huge amount, about like the relative transfer across all of those surfaces, but your risk of getting that in any part of your body is gonna depend on the amount of activity happening in that space. And because different sexual partners might carry HPV, then it will depend on the number of sexual partners that you're having and the sexual behavior.
Gaby: So this actually gets at something that comes up with my patients a lot, which is this question of: if I am not having penetrative sex, then am I at risk for HPV? And it's what Dr. Berner says. Lots of things can bring HPV in contact with a vaginal canal. And the cervix that lies at the end of it. So yes, certain sexual activity like penetration is going to increase the risk of HPV getting into that part of the body, but we don't have the ability to say the risk is zero if there's no penetration involved.
Sam: S,o a friend who's also an infectious disease trained doctor once described HPV like glitter: It's something that once it's on your body, it's there. It's hard to get off and it can kind of move around. So even if you put glitter on your eyes, you're gonna find it everywhere else. And HPV kind of works the same way.
Richard: Which is to say even if you don't use your vagina for sex and never have, there's still a benefit to screening.
Dr. Berner: It also depends on whether that virus stays there. So most of us will clear that virus. Most of us will have the virus at some point in our life, and our immune system does its job and it gets rid of the virus. But some things cause us to keep hold of the virus a bit longer. For example. Smoking, which lowers your immunity. If you are someone living with HIV, whether it's controlled or not, the better it's controlled, the better your chance of clearing the HPV virus, but it still lowers your immunity, maybe you take other drugs that lower your immune system for maybe an autoimmune condition or because you've had a transplant, that will also affect things. And, and just being generally run down that there's not amount of research on that. We all know that affects our immune system. So it's one of those things that the more we can do for all of our overall wellbeing, the better our immune system, the better the chance that we clear HPV.
Gaby: A common question I get from my patients is: how does testosterone impact cervical cancer risk? And fortunately, Dr. Berner is literally the expert to ask this question to.
Dr. Berner: I feel like, for some reason because there are some cancers that are responsive to hormones. Everybody starts thinking about cancer and hormones and gets really freaked out and thinks that hormones must be a risk factor for everything. And we really do need to think about it. 'Cause actually the way our bodies and immune systems respond is driven a bit by biology and biology of hormones and biology of chromosomes. But we don't have anything definitive around, HPV itself and testosterone directly. We have some clues that need a bit more research. So one of them is that testosterone causes a change in the bacteria that live in the vagina. That mean that maybe HPV might stick around a bit longer or flourish there? Just because it affects the immune response is affected by the bacteria in the area. So, so there is a clue that perhaps that might play a role.
Sam: So maybe testosterone causes HPV to stick around a little longer, and the same way that other risk factors like smoking do.
Richard: On the other hand, Dr. Berner says that some of her new research is suggesting just the opposite, that testosterone might have no effect on the rates of cervical changes.
Dr. Berner: I was part of a piece of work with the Dutch who have this cool way of matching, samples that have been removed during gender affirming surgeries and looking at pap results. and they can match it with people being on testosterone. And there was no signal that testosterone seemed to make a difference to people getting kind of cervical pre-cancers or cancers. In fact, the rates of pre-cancer are a bit lower in that population. But it's one study and it's a little bit limited. So from what we know at the moment, no evidence for, but some things to be aware of.
Gaby: So the evidence is a little bit murky, but I think the bottom line is that there is no definitive or strong evidence to suggest a significant change in cervical cancer risk simply from taking testosterone. And I'm very hopeful that that Dutch study ends up being the first of many that prove that T actually reduces cervical cancer risk. But obviously I have wishful thinking here.
Sam: And at the end of the day, Dr. Berner makes a point that HPV is not something to be ashamed of.
Dr. Berner: There's a lot of stigma around HPV, but it's important to know that it kind of is everywhere. And so whilst sexual behavior is a risk factor, it's we shouldn't be stigmatizing it." So, well, you didn't keep yourself healthy 'cause you kept hold of the HPV." It happens.
Gaby: It does, and the great news is that there are ways to screen for it. So even if you do feel like you may be at risk for HPV, there are things that can be done to detect and prevent the cervical cancer that comes as a consequence.
Richard: And even more importantly, there are ways to ensure that that screening is done in an affirming and inclusive way. So keep listening.
[TRANSITION MUSIC]
Gaby: Okay. So we've covered some scientific fundamentals, how HPV and cervical cancer are related. And now we're ready to talk about pap smears.
Richard: For that, we're gonna turn to our second expert guest.
Dr. Hedian: My name is Helene Hedian, and my pronouns are she/her, and I'm an associate professor of clinical medicine. I'm a primary care physician and I do a lot of gender affirming care and care for the LGBTQ plus community in Baltimore, Maryland.
Sam: Dr. Hedian explains what actually happens during a pap sear.
Dr. Hedian: So people often use the words, "pap smear" interchangeably with a pelvic exam. A pelvic exam is when you go to the doctor or to a clinician and they do an external and internal exam of your genital region. If you're a person who's assigned female at birth or who has a vagina. That Pap smear is , a test that can be done during a pelvic exam where the clinician will take a Q-tip basically and they'll insert it into the center of the general canal, and they'll take a small sample of cells just by rubbing it on the tissue at the opening of the uterus. That is the area where people can develop cancer. That's where the first changes of cancer will show up.
Sam: So as for how often you need a pap smear, there are guidelines on that too. Very, very robust ones. For those wondering, there is no difference in the guidelines based on gender identity. If you have a cervix, these guidelines apply and whether or not you're using testosterone, these guidelines also apply.
Dr. Hedian: The guidelines are, from 21 to 29, a pap smear every three years, assuming the results are normal, and then from 30 to 65, you can do every five years if you co test get an HPV test together with a cytology .
Sam: Cytology is the medical term for a sample of cells.
Richard: Most people with the cervix need a pap smear about every three to five years if results are normal. If the results are abnormal, we usually check more often to monitor any changes closely. In some cases, a colposcopy is recommended.
During a colposcopy, a gynecologist uses a special magnifying glass to look closely at the cervix and may take very small tissue samples that are called biopsies to better understand what these cells are looking like.
Gaby: I wanna acknowledge that both the pap smear and this follow-up test, a colposcopy, we're talking about invasive tests. These are genital or pelvic exams with a tool called a speculum that's placed in the vagina so we can collect cells from the cervix.
Kellan: Before I had been really hesitant especially being in settings that were not as specialized with like LGBTQ+, specifically trans, health. It just felt uncomfortable and vulnerable in a way that I wasn't quite ready for.
Sam: Kellan's hesitancy is something we encounter in clinic all the time and for so many reasons. For starters, to use the not-so-medical term, it's someone's private parts being examined.
Richard: While not the case for everyone, folks who are survivors of sexual assault may find that the discussions or exams of their genitals require confronting some pretty intense emotions and possibly trauma.
Gaby: And for some, the idea of having anything placed inside of the vagina, especially if it's not a part of their usual sex life, or it's been painful in the past, that can be really stressful.
Sam: But for trans people specifically, there can be so many other reasons that a pap smear might feel intimidating or very unappealing. Because so much of medicine still equates anatomy with gender. An exam that focuses on the genitals puts folks at risk of being misgendered or having their gender identity challenged by providers. That might include the fear of being misgendered, having your identity questioned, being touched without clear consent, or just being in a space that feels unfamiliar or unsafe.
Richard: And not to mention in addition to the usual risks of transphobia in a clinic like intake forms that don't match your gender or staff who aren't sure how to address you, a pap smear has a lot of gendered connotations.
Gaby: And for some, that's why queer spaces like a Pride Clinic might make it a bit easier.
Kellan: I always said no because I was afraid to take up space. I was afraid to mess with their schedule by taking a few extra minutes to ask some questions. It's always been very dry and very quick ask. And then just like a move on, which also, I don't know, to me, sends a bad message. I was afraid that if I asked questions as a trans person, it would not be their problem. It would be mine, right? Like if I asked for something or asked a question or stated a preference, it would be me making their lives difficult. That is what I worried about. And again, that's also I think a little bit on being socialized female, which I could talk about for years and years. So I continue to be hesitant to take up space. But I think it's really important to voice all your questions, comments, and concerns.
Sam: I'd like to point out a personal point, which is that even as a doctor when I go to the dentist, which, you know, is generally not a threatening existential experience, I also feel that sense of worry of taking up space or asking a quote, annoying question. So dynamics in any clinic can be really hard for everyone and certainly can be harder when your gender identity already feels so vulnerable.in
Richard: absolutely, and this is why clinicians like Dr. Hedian make a point of building in space for these conversations into their general approach so that there's not pressure to get everything done on the spot in the same visit.
Dr. Hedian: Anytime I bring up a pap smear I always tell patients "We're not gonna do it today. I don't surprise people with Paps. I don't believe in surprise paps. So we're gonna talk about it and make a plan for it. We'll see how comfortable you are and if this is a test you wanna get done in my clinic, then we'll schedule an appointment specifically for that." We'll all walk into the room knowing that that pap's gonna happen that day. No surprise Paps, but even given all that, if you walk in that day and you're having a terrible day and you just can't do a pap, that's also fine. Still come and we'll talk about it. We just won't do the test. We'll figure out sort of why you're feeling that way and what we can do to make you more comfortable.
Richard: Video visits, for example, can be really useful here as a way of offloading the pressure.
Dr. Hedian: So I'm a big fan of if you, if you're a patient and you know that you need a pap smear or you think you might need a pap smear and you wanna ask your doctor about it, but you don't wanna get pushed into an invasive procedure before you're ready. I'm a big fan of asking the question during a video visit because nobody can do a pap smear on you during a video visit. They just can't. And if the conversation goes well and you feel comfortable with that provider, great! Schedule an in person and do the test, if you want to. If it doesn't go great, oh well. I have a gynecologist that I work with who calls it, "let's do a video visit for a vibes check first." She's a gem.
Gaby: And just to make this clear for those listening, Dr. Hedian and all of us here at QHP, we really mean it. You can ask for more time and utilize the resources that you have, like virtual visits to make sure all your questions are answered. And in fact, we want you to do that. It's better for you and it makes the experience more seamless for the clinician too, because if you think about it, it effectively gives us double the time we have a full visit to do all the information sharing all the questions, and then a full visit to focus on the procedure and just making sure the person having the procedure feels as comfortable as possible.
Sam: Plus, as Kellen's doctor reminded him, just having that conversation is an important first step towards your health.
Kellan: She also framed it as, I don't need to get that pap smear that same day to start taking care of myself. Like even just starting that conversation is an act of self care and a great next step.
Richard: And that's exactly why even small steps, like starting a conversation with your doctor can be a big deal. It's about taking care of yourself bit by bit.
Sam: Just like me at the dentist, but also not like me at the dentist, Kellan pointed out how shame can be a huge barrier in finding the competence to ask all your questions.
Kellan: I think I was initially a little ashamed of myself because I had not been taking care of, my health, outside of doing what I needed to do to receive my weekly testosterone. I mean, God, talking about shame as a trans person, like that could be a whole episode in itself. I've struggled with a lot.
Gaby: And that shame isn't just about falling behind on a preventive test. There are a lot of layers. So for some trans guys, all of this screening can get tangled up with ideas about masculinity and how men are "
Kellan: Man, we live in a society and men taking care of themselves too is something that isn't always encouraged, or at least in my life and in my community. Being a trans guy is definitely weird in that way because you're dealing with being trans, but also you're. dealing with being a man, which is, a weird and wacky journey for sure. And just thinking about the male role models, quote unquote in my life, I'm not sure I always see them taking care of themselves, you know, and there's definitely like a thread of like toxic masculinity that runs as an undercurrent to some of these things. And I think when I was first starting to transition, I thought that in order pass or to be more of a man or to X, Y, Z conform to society in use certain ways. I thought that I had to forgo a lot of the self care, especially in a clinical setting. It's never too late to start taking care of your health. It's never too late to start advocating for the things you need and the things you want. So what if I haven't done this in five years? That's okay. Let's start today.
Sam: And from what Dr. Berner's research shows, these feelings of shame and guilt are actually super common for trans people and something that trans people have actually come to expect from providers.
Dr. Berner: Actually some feedback from different community groups was like, the biggest thing that stops me going is that I don't wanna get shouted at or like moaned at. So like there's something really important about that nonjudgmental approach and I think, that can't be promised, from a clinician, but it's so important and I think we are talking to you, those listening and saying you should go, we can't promise that someone might not say that, but what we can tell you is that they have no right to say that.
Richard: Maybe someone has no qualms about asking all the questions, which we think is awesome. But the reality is that we're all people with busy and complex lives, and sometimes getting a pap isn't someone's highest priority.
Dr. Hedian: I think it's just like not the most important thing on many people's list. You know, like getting groceries, like doing your job, going to school, like dealing with pet or child of family emergencies, like those things all end up higher on the list than getting an organ screened when you have some kind of relationship with that organ. I don't really wanna guilt people into taking care of their health. Even if it's been a long time since somebody's had a cervical cancer screening, or if they've never had it, even though they sort of know that they're due for it, I say, "listen, this test is important, but it's not urgent, right? If you're not having symptoms, this is just like a routine screening test and we should do it, but we shouldn't feel bad about not having done it before now, 'cause honestly, we can't control that anyway, and we should just do it as soon as we can and when we're all comfortable with it."
Gaby: Not to mention Dr. Berner pointed out that trans folks in the world right now are under a lot of stress outside of their routine healthcare.
Dr. Berner: There are tons of reasons. In the world, why it's difficult to go and get screened right now. And so there is no shame. It's really important for you to know that whatever the reasons were that you didn't get screened, they're all really valid to you. But making the choice to get screened now and underground, your risk is never a bad choice.
[TRANSITION MUSIC]
Sam: Alright, we've talked a lot about shame hesitation, and how starting the conversation can be the first step in taking care of yourself. This next section is gonna lay out a roadmap of how a pap smear. The before the, during the after can be made affirming and comfortable.
Dr. Hedian: Whenever I'm getting ready to do a pap for the first time on a patient, this is in the planning conversation before the actual visit. I ask if they've had a pap or a pelvic exam before and what their experiences were with that. I try not to assume that their previous experiences were good or bad. If they were good, I ask what, you know, helped it be a comfortable experience to see what we can replicate for the future if it was bad, It gives me a helpful idea about what to avoid and how to reassure the patient that, how we can make this experience at least more safe for them this time.
Sam: So yes, providers do want to hear about what prior experiences have been like. It helps us anticipate any concerns and the more planning we can do, the better the experience is for everyone.
Richard: Dr. Hedian also makes time to explain how everything actually works, so the patient knows what to expect.
Dr. Hedian: There's something about the speculum. I don't know, like people see them on television. But they've never really like touched them or interacted with them. It's like very unknown. And so as I'm talking about getting a pap at a future visit, I'll usually just like take out a speculum unused still in the plastic and like hand it to the patient and I'll say like, this is the tool that will help me see your cervix. This is why it's shaped this way. This is what, how we'll use it. This is where the light goes. Just so that it demystifies the process a little bit.
Richard: For folks who use gender affirming testosterone, Dr. Heian also uses this pre-AP time to talk about ways to make this procedure more comfortable, which can even include things like estrogen.
Dr. Hedian: For transmasculine folks, people who've been taking testosterone for a period of time, it can lead to some atrophy, and that can make the tissue more sensitive, Which makes the pap experience a little bit more uncomfortable. From a medical perspective. It can also increase the risk of unsatisfactory paps. So, you know, even when everything is done right during the procedure, the patient might have to come back for a repeat test.
Sam: The science behind this is relatively straightforward. Testosterone can change the tissues in the vagina and cervix. It can cause atrophy, which means the cells become thinner and the thinning can feel like dryness, which can definitely be addressed with your clinician. And that thinning can also make it harder to collect a sample of cells.
Richard: One nice thing is that with newer technology, we're moving towards focusing more on HPV rather than this cytology or cells themselves. This is good news because HPV testing is much less affected by testosterone. So inconclusive paps are much less of an issue.
Dr. Hedian: One of the ways to mitigate that is to apply a topical, low- dose estradiol a couple times a week for about four weeks before the procedure. So this is off-label use of estradiol, but supported by the guidelines. Um, and it, um, helps reverse some of the atrophy, makes the procedure more comfortable and reduces the incidence of unsatisfactory paps.
Sam: A question we hear a lot from patients is: wait – will estrogen cream mess with my testosterone?
Dr. Hedian: The amount of estradiol that we're giving for this indication and in this route is a very low dose and a small amount of it is gonna be absorbed throughout the body, but not enough to interfere with what's going on with your testosterone. In my experience, if somebody applies the topical estradiol daily for a long period of time, that can trigger bleeding, and so it is important not to do it all the time, but really like once a week or twice a week for a few weeks, and that's generally sufficient. But some people don't really wanna do that, and they'd rather just get the test done and get it over with. That's also fine.
Gaby: So let's be clear about this. People shouldn't feel pressured to use estrogen if they don't want to, but it is a great option to help with comfort, and it doesn't impact the level of testosterone that somebody's body sees while they use it.
Richard: Besides topical estrogen, other medications can be used to make paps more comfortable as well.
Dr. Hedian: So for anxiety we talk about you can take an as needed anti-anxiety medication before the procedure. Not every person is gonna be anxious about this type of procedure, but if you don't ask ahead of time, you won't know who would benefit most from those types of treatments.
Richard: So listeners should definitely feel entitled to discuss medications before the pap that can help. And more importantly, as Dr. Hedian points out, should feel fully entitled to discussing pain during the procedure.
Dr. Hedian: As far as pain, it's not normal to have pain during a pap. And if you have pain, you should tell your provider. If you want to stop, you should tell your provider and they should stop. Right? That's part of putting the power in the hands of the patient. And this is something I try to be intentional about saying every time is like, if you wanna stop at any point, just tell me and we'll stop. And the procedure's done.
Gaby: I completely agree, and this is literally exactly what I say to my patients and is really important for people to know, whether it's physical pain, whether it's stress, anxiety, emotional discomfort of any form. I wanna hear that right then and there so I can make adjustments in real time or stop the procedure and make sure that we're doing this in the best possible way for the person having the procedure.
Richard: Okay, so we've talked about the pre-pap visit: speculum show and tell plus or minus estrogen and some anxiety or pain medicines. What happens day of to optimize someone's comfort?
Dr. Hedian: I think different strategies might make different people feel comfortable during a pap smear. Some patients might prefer to have their provider talk them through every step in the procedure so that you know, no touch or no step happens without the provider saying verbally, beforehand, I'm going to do this, I'm doing this now. And that's very valid. Other patients might prefer to. Just sort of pretend that they're somewhere else and this what's happening is not happening. And they might wanna listen to music or look at a book or do something else to distract themselves during the procedure. And that's totally fine too.
Sam: One thing Dr. Hedian finds many patients appreciate is having a trusted person in the room with them.
Dr. Hedian: I'm a big fan of encouraging patients to bring a support person with them to the visit because it helps make everybody feel a little bit more comfortable and, you know, in medical settings. It's easier to speak up on behalf of someone else and elevate their needs sometimes than it is to elevate your own needs. So having somebody there who can act as your advocate during this type of test is a useful thing I think.
Sam: FYI: all clinics have a policy that for an invasive exam, like a genital breast or butt exam, there is a requirement for a chaperone to be in the room. If an additional person makes you feel more comfortable, that is also something you can let your provider know. 'Cause you can often opt out of the chaperone if that is not the vibe for you.
Gaby: And from experience, I definitely have patients who, for pap smears, want that additional person and we schedule their visits around when that person can be there. And then I have some patients who definitely don't. We see both. So please don't be afraid to ask for what you need.
Richard: If you are thinking about getting a pap smear, just know that because you get one today or this year doesn't mean you have to get the next one exactly when the guidelines tell you to.
Dr. Hedian: I tell people what the guidelines are and let them make their own decisions. So I do co-test routinely to try and minimize the number of paps somebody might have to have in their lifetime. But my general advice is these are the guidelines. I do recommend this test. It's important, but it's not urgent. And as long as you have this organ, we should be taking care of it.
Gaby: Look, if you do wanna be screened as often as the guidelines suggest, that's great. And if you don't, that's okay too. Any screening is helpful, and as Dr. Berner points out, the guidelines aren't going to perfectly encapsulate your individual risk.
Dr. Berner: We produce screening guidelines on a population level. We are moving towards tailoring it, but no, almost never do we get it perfectly right. You know, we tell people to come at a specific interval for screening. But there are what we call interval cancers that also happen. And whose fault is that? That person might turn up every year and then be unlucky. And it might be that depending on your sexual behavior as well, like maybe that is the right level for your risk. And we just don't know. So we haven't got this tailored yet. We certainly don't have stuff around screening tailored well for the trans community.
Gaby: To use the QHP mantra: we just don't have enough data yet, and the hope is that we'll start to, soon.
Richard: Another thing to note about variations in the guidelines. The guidelines don't yet account for vaccination against HPV.
Dr. Berner: There's some research coming from the university that I work at to suggest that actually in the wake of vaccination there was some research to suggest that if you got the most recent vaccine, which covers many, many types, then actually maybe you might only need two cervical screens ever in your life. Which is pretty amazing.
Richard: This data is hot off the press. So for now, what most clinicians feel confident in saying is that folks who got their HPV vaccination series, the brand name is Gardasil, have lower risk of cervical cancer. But the guidelines don't yet have a separate section for folks who are vaccinated versus unvaccinated . So keep your eyes peeled 'cause that's coming.
Sam: All of which is to say guidelines are to guide. If there's something about you that you think may change the guidelines for you, ask your provider, and if you find that the guidelines don't fit perfectly for you, any screening is always an act of self-care.
Dr. Berner: I'm a big believer in harm reduction. I'm a big advocate of that. And so I think yes, the better than nothing is important, but what's really important is you have the information as best you can to make that decision. So if you're choosing a different interval doing that when we are fully informed, then that's the most important thing.
[TRANSITION MUSIC]
Richard: In the previous section, we talked about how to make sense of the current cervical cancer screening guidelines. This final section is about what's next, the new frontiers in screening. But to get there, Dr. Berner starts at the very beginning.
Dr. Berner: When we first started thinking about reducing cervical cancer, what we were doing, we were taking cells from the cervix, looking under the microscope and to say, these, do these look weird?
Gaby: What she's talking about there is the pap smear.
Dr. Berner: And then we started to understand that cervical cancer is caused by HPV. And actually the biggest risk factor is having the HPV there. if you've got a positive HPV sample with the bad cells, then that's what's really leading to a problem. , And so what we started to do was to test for HPV first and say, "oh, actually if you haven't got HPV, the chance of there being an issue with the cells is nonexistent. So we don't need to worry about, even looking at the cells, we can just throw the little brush away, and just have tested for the HPV. " And if we can do that, maybe we can just take a swab, from the vagina or the way that you refer to it, and maybe that will mean that people don't have to come for such an invasive test. Or maybe it's just a little bit more comfortable if you don't need the speculum part. So we started with clinicians doing the vaginal swab, we figured that actually, patients in public are pretty smart. Maybe they can swab themselves, but maybe we should make sure that the transport is okay and it gets to the clinic. So we started doing swabs in the clinic,
Gaby: And then the question became: were those swabs as good at testing for cervical cancer?
Dr. Berner: And actually those studies were done over a decade ago, including a specific study. for trans men and non-binary people. Even then we worked out that actually no brainer, way more acceptable, to do the swab yourself and, pretty accurate. The inaccuracy sort of comes the fact that, we're not all perfect at doing things exactly the way a clinician would. But not too bad. So we've known this as promising for a really long time.
Richard: And this is where Kellan's story comes in, because this is the swab he was offered in clinic that you heard at the top of the episode.
Kellan: So I recently started going to an LGBTQ plus focused healthcare clinic, here in New York City. And I went in just to establish primary care, initial appointment type situation. And they asked me if I wanted to get a pap smear and my first reaction's kind of like, "No, I don't need that." But then my amazing doctor – she told me that there's now an option to do a self-administered pap smear, and I immediately pivoted to say, "Oh my God, yeah, I'd love to do that." Because being able to take something like that into my own hands as a trans person and have that autonomy over my body and over this really vulnerable experience, meant a lot to me, was really exciting.
Sam: So here is what a self-administered HPV swab looked like for Kellan:
Kellan: So I was sent into the hallway bathroom. You know how if you're at the doctor's office, you go back to the exam rooms and then there's a – a hallway, single stall bathroom? I was sent there and inside of that bathroom. There was a poster that reiterated the verbal instructions I was given by my doctor. So there were no awkward moments of – I was kind of nervous about like making it halfway through and then like forgetting what I'm supposed to do next and then having to like awkwardly come back outside. But they had really thorough instructions that mitigated that and totally erased that fear. And then when it was done, I think I just walked it back to the doctor inside of the exam room. And it just felt great to not have something like that yet somebody else's mercy, but just rather be my own thing that I was gonna inform myself and 'cause I care about myself.
Sam: We asked Kellan how he'd describe the actual test itself, and his response was both incredibly illuminating and a little amusing.
Kellan: I mean the best way I would describe it is like a vaginal COVID test. I'd say like anyone curious on the instructions, like think COVID test, that's pretty much what was up. I'd say levels of discomfort similar to a self-administered COVID test, you know, um, they weren't asking anything uh, and anything that felt like too hazardous. And yeah, just by nature of it being something you do to your own body you know the ins and outs of your own body in a way that no doctor ever could.
Sam: Kellan's story reflects how game changing the self-swab HPV test is. The test is less invasive, it's more empowering, and it's less anxiety inducing doing this test by yourself and on yourself.
Richard: And it can unlock the possibility of cervical cancer screening for people like Kellan who would otherwise have said no.
Gaby: As Dr. Berner points out, there's a lot more good stuff to come down the pipeline.
Dr. Berner: If people can swab themselves, maybe they can do this at home, and maybe that makes it much more accessible, to be screened than having to come into a clinic, make the time, maybe go through the trauma that might be associated with being in a healthcare setting and all of the other barriers that come in with engaging with healthcare for trans folk right now. So there've been a few self sampling studies with vaginal swabs. And those were pretty good at saying, "well, this is, this is pretty accurate. And it improves people coming."
Gaby: So for what it's worth, in May of 2025, the FDA officially approved the Teal Wand, which is a swab specifically designed for people to take vaginal HPV swabs at home.
Richard: It's definitely worth asking about to see if that's offered at your clinician's office. At the time of this episode's publication, this is still a very recent change. We hope more and more clinics start offering self swabs, both in clinic and at home as time goes by.
Gaby: And if you think all of this is exciting, wait till you hear what Dr. Berner tells us next.
Dr. Berner: The kind of new kid on the block is urine. Because actually could we do something that doesn't even involve that part of the body. So if it's physically difficult for you, if there's something quite traumatic that comes up, would urine be a good alternative? And I think you're thinking, "well, hang on, you've just told me that you're taking a swab from the vagina and I know my anatomy and the urine doesn't come out that whole, so why are you talking about urine?" So, urine catches the bits of HPV that might be on the surface of the genitals, if it's the first urine you've done. And there's a particular device. That's really good at capturing it really well and preserving it. And then we can test for HPV on that sample. And so there's a study called ACES in the uk, which is letting people choose between a swab from the vagina or a urine sample that they do at home and return.
Gaby: From an accuracy perspective, all I'm gonna say is keep your eyes peeled because the preliminary data for this looks really promising and people like Dr. Berner are working on getting a better sense of just how good a test it is compared to the standard measures like vaginal swabs.
Sam: But as far as how acceptable the test is, well would you rather pee into a cup or perform a test that involves putting something inside your body?
Dr. Berner: Again, no brainer, like: doing urine's quite good.
Richard: And not only that, it does have some fringe benefits as well…
Dr. Berner: And this Colli-Pee device that you use for the urine is actually, like a stand-to-pee device. So, for people who have not yet had bottom surgery, it can be really affirming to like stand there and be able to urinate standing, and then the rest goes into the toilet. So there's quite a lot of options. And for all that progress that we just described, there are still some open questions and work to do. The big piece here though is, you know, we've mentioned all these different screening modalities, but right back at the beginning I mentioned the cells part. And so if any of these HPV tests come back positive, we don't have the cells, we still need the cells. What happens if people do these tests and they come back positive? Do people then go for the follow up? Because we mentioned the shame part and the last thing we wanna do is have loads of people with positive tests just at home, experiencing shame that they can't physically go for the exam. So how do we work out how many people go and what support can we give to people going for tests, but also the clinicians treating them to make sure that everybody has a good experience and that ultimately people stay engaged with screening and we detect more cancers sooner.
Kellan: Yeah, man, that is, that is tough. That is tough. I do think, that is part of what's gonna be difficult about this new era of self-administered paps. What happens next? I guess just as with all of this, one step at a time, one conversation at a time, one question at a time, I mean, at least in my experience, the more information, the better. I love to know what's happening. That's something I've learned with therapy too, right? Information can ease anxiety.
Richard: That's really the thing: just knowing what's going on and taking that step can really help a lot. At the end of the day, Kellan reminds us that a pap isn't just a test. It can have a ripple effect on your health that alone can make it worth doing.
Kellan: That pap smear experience 2000% enabled and empowered me to continue on this self-care journey, absolutely. I think there's a term for it, like, habit stacking. You build and you build, right? So it's like: I got the pap smear. Then that made me want to address this other, you know, hormonal thing that came back in my labs and then that made me want to come on this podcast, honestly. And that made me want to start talking with other queer people, and that made me want to go advocate inside of the sport that I'm playing…and then it builds and builds and builds in such an exciting way. So, yeah, just being with the right people who will help you take that first step. I feel so lucky because man, I – I love being trans. I really do. I love being a trans guy.
[QHP THEME MUSIC STARTS]
Richard: QHP is a power sharing project that puts community stories in conversation with healthcare expertise to expand autonomy for sexual and gender minority folks.
Gaby: Thank you to our community voice, Kellan Oelkers, and our healthcare experts, Helene Heian and Alison Berner. We would like to also thank our community reviewer. Fiorenza Piccorelli.
Richard: For more information on this episode's topic, check out our website at www.queerhealthpod.com.
Sam: Help others this information by leaving a review, by subscribing on Spotify or Apple Podcasts.
Richard: And we are on social media. Our handle is at @QueerHealthPod – please reach out to us.
Sam: Thank you to Lonnie Ginsburg, who composed our awesome theme music, and to the Josiah Macy Jr. Foundation who supported some of the tech we used to produce these episodes.
[QHP THEME MUSIC ENDS]
Richard: As always, opinions in this podcast are our own and do not represent the opinions of any of our affiliated institutions. And even though we're doctors, don't use this podcast as medical advice and instead, consult with your own healthcare provider.
[QHP PERCUSSION MOMENT]
Sam: Unlike when I'm at the dentist, you should let us know if there's –
Gaby: I feel bad for your dentist, Sam.
Sam (chuckle):. No he's such a nice guy and he lives right across - he like like works across the street. He's so cute. No, he's funny and will never hear this.