Tips for screening trans and non-binary patients

Preparation

1. Make the offer: People who are registered as male on their NHS record will not receive an invitation letter to go to a cervical screening, even if they have a cervix. Keep in mind when seeing trans, non-binary, and intersex patients whether they may need a screening test. Make them aware if they are due, and chat them through what the test is and why they might want to have one.
2. Don’t assume: If you don’t already know, check with your patients what their pronouns are. Check what gender-affirming care your patient has had, if any. Also ask your patient what they prefer their genitals to be called, avoid words like vagina/vaginal unless the patient has told you it is okay for them.
3. Set expectations: Let your patient know that there is no pressure to actually have their screening done in your first appointment together. Sometimes multiple appointments are needed so that trust is built up and your patient can prepare themselves in whatever way they need to, before a sample can actually be collected from their cervix. Try to avoid language such as ‘unsuccessful’, ‘inadequate’ etc.
4. Show and tell: Show your patient the equipment you will be using first. Knowing what to expect can help make things seem less scary. Show them the speculum and brush you plan to use and talk them through the procedure step by step before you begin.
5. Be aware: that your patient may not have experienced any vaginal penetration, which includes vaginal intercourse, using sex toys or tampons. Therefore they may find a speculum painful. Try the smallest size speculum, and make sure it is lubricated.
6. Relaxation is key: As humans, when we hear the words ‘just relax’, we often do the exact opposite! But if you can, let your patient know before your appointment together that being relaxed is important and will make the screening process easier. What normally relaxes them? Let them know they can bring in their favourite music, a stress ball, or a friend or partner for support. Whatever they can do to try and feel as calm as possible.

Performing the screen

1. Control: Throughout the appointment remind your patient that they are in control, and that they can tell you to stop or change their mind at any time. Some patients can feel very vulnerable during a screening appointment, so letting them know that everything is on their terms can help balance this. Letting them know that if it is easier for them they can help you guide in the speculum. Get informed and explicit consent, and double or triple check!
2. Moisture: If your patient is taking testosterone, they may have less natural vaginal lubrication, which can make a cervical screening test more uncomfortable for them and harder for you in terms of inserting the speculum. Advise them to use a natural vaginal moisturiser before the appointment to make using a speculum easier and more comfortable. An oestrogen cream is also something that is helpful in this situation, but understandably many trans men will not want to use anything oestrogen-based, even if it is a localised product. Explain to them how the cream works and how it won’t have any wider effects on their body.
3. Patients first: If your patient is finding the appointment really difficult, or taking the sample is causing a lot of discomfort or pain, it may be better for your patient to not go through with the screening test at this moment. It might be better to recommend trying again at another appointment. Sometimes, after thinking about their risk of having HPV, i.e. their sexual activity/history (if any), a patient may decide against completing their screening. Their overall wellbeing is a priority, particularly if the risk of cervical cancer is low.

Follow up

4. Plan b: Sometimes it just isn’t possible to finish the cervical screening test, either because you can’t take the sample or your patient would prefer not to go ahead with the appointment. If appropriate, you might want to tell your patient about self-testing kits that can be done at home. It will come at a financial cost to them, and the chances of a poor sample or inaccurate result are higher, but is better than no test at all.