Transgender patients and the physical examination

Introduction

Physical examination should be relevant to the anatomy that is present, regardless of gender presentation, and without assumptions as to anatomy or identity. Sensitive history taking is required to understand the myriad and individualized changes and characteristics in the context of hormone administration and surgical intervention. Consideration should be given throughout the visit to potential prior negative experiences within the health care setting, including discrimination as well as physical or emotional abuse.[1]

When conducting a physical exam, providers should use a gender affirming approach. Gender affirmation is when an individual is affirmed in their gender identity through social interactions.[2] This includes being referred to by the correct name and pronouns during the entire visit. This may also include using general terminology for body parts, or asking patients if they have a preferred term to be used.[3] An examination should only be performed of those body parts that pertain to the reason for a specific visit. For example, examination of the genitalia is not appropriate in the context of an acute visit for an upper respiratory infection.

Secondary sex characteristics may present on a spectrum of development in patients undergoing hormone therapy, to some degree dependent on duration of hormone use and age of initiation. Transgender men may have facial and body hair growth, clitoromegaly, increased muscle mass, masculine fat redistribution, androgenic alopecia, and acne. Transgender women may have breast development (often underdeveloped), feminine fat redistribution, reduced muscle mass, thinned or absent body hair, thinned or absent facial hair, softened, thinner skin, and testicles that have decreased in size or completely retract.[4] Patients who have undergone gender affirming surgeries may have varying physical exam findings depending on the procedures performed, approaches used, and occurrence of complications. Providers should maintain an organ inventory to guide screening and management of certain specific complaints.

Special considerations for a vaginal exam in transgender women

(See also guidelines for sexually transmitted infections, and for vaginoplasty)

The anatomy of a neovagina created in a transgender woman differs from a natal vagina in that it is a blind cuff, lacks a cervix or surrounding fornices, and may have a more posterior orientation. As such using an anoscope may be a more anatomically appropriate approach for a visual examination. The anoscope can be inserted, the trocar removed, and the vaginal walls visualized collapsing around the end of the anoscope as it is withdrawn.

Special considerations for conducting a pelvic examination with transgender men

(See also guidelines for sexually transmitted infections, and for cervical cancer screening

The pelvic exam may be a traumatic and anxiety inducing procedure for transgender men and other trans-masculine persons. Transgender men are less likely to be up to date on cervical cancer screenings [5] and have a higher rate of inadequate cytologic sampling.[6] It is essential to make clear to the laboratory that the sample being provided is indeed a cervical pap smear (especially if the listed gender marker is "male") to avoid the sample being run incorrectly as an anal pap, or discarded. The use of testosterone or presence of amenorrhea should be indicated on the requisition.

Should the individual express distress or concern about the examination, it may be deferred until a later date once a trusting relationship has been developed. A website with further details on pelvic examinations and screening can be found at checkitoutguys.ca.[7] Various techniques can be used to make a pelvic examination (including bimanual and/or speculum exam) less uncomfortable

• Discuss procedures with the patient beforehand, including the order in which steps will occur. Allow time for the patient to express any concerns prior to beginning the exam.
• Allow the patient to have a support person in the room, listen to music on headphones, or utilize any other strategies they may have to provide distraction during the exam.
• Explain each step in a clear a direct way throughout, such as saying: "I will touch with my hand now," "you will experience some pressure next," "you will hear the clicking noise of the speculum now," and reminding the patient that the exam can be stopped at any time at their request.
• Avoid using medical terms for body parts, unless discussed beforehand that these are preferred terms the patient would like you to use. Some patients may prefer to refer to their vagina as their "front" or "front-hole."
• Offer the use of a mirror to allow the patient to directly observe the exam.
• Administration of an oral benzodiazepine 20-60 minutes prior to the exam may be helpful for those with severe anxiety.
• Administration of vaginal estrogens commonly used in menopausal management for 1-2 weeks prior to the exam may decrease the vaginal atrophy often seen with testosterone therapy.
• Allowing for self-collection of some tests may preclude the need for a speculum exam in certain scenarios, such as a swab for wet prep to analyze abnormal vaginal discharge. Specimen self-collection for HPV testing is currently under investigation.
• In the case of refusal of a speculum exam, consider offering an external and/or bimanual exam as an initial step toward establishing comfort and trust. A positive experience may lead to the patient considering further examinations in the future.

Other special considerations

Binding of the chest to create a masculine appearance may lead to skin breakdown or other complications of the skin. Patients may be hesitant to remove the binder for a physical exam.[3] Appropriate and sensitive history taking and education about safe binding is recommended for all trans male patients.[8]

Tucking of the testicles and penis may lead to hernias or other complications at the external inguinal ring or skin breakdown at the perineum. Thorough and sensitive history and education is recommended for all trans women.[8]

When appropriate and indicated, findings suggestive of intersex conditions should be further evaluated.[4]

References

1. Grant JM, Mottet LA, Tanis J, Harrison J, Herman J, Keisling M. National Transgender Discrimination Survey; Report on Health and Healthcare [Washington, DC: National Center for Transgender Equality and National Gay and Lesbian Task Force; 2010 Oct [cited 2016 Mar 10] p. 1–23.
2. Sevelius JM. Gender Affirmation: a framework for conceptualizing risk behavior among transgender women of color. Sex Roles. 2013 Jun 1;68(11-12):675–89.
3. Dutton L, Koenig K, Fennie K. Gynecologic care of the female-to-male transgender man. J Midwifery Womens Health. 2008 Aug;53(4):331–7.
4. Feldman JL, Goldberg JM. Transgender Primary Medical Care. Int J Transgenderism. 2006 Sep 1;9(3-4):3–34.
5. Peitzmeier SM, Khullar K, Reisner SL, Potter J. Pap test use is lower among female-to-male patients than non-transgender women. Am J Prev Med. 2014 Dec;47(6):808–12.
6. Peitzmeier SM, Reisner SL, Harigopal P, Potter J. Female-to-male patients have high prevalence of unsatisfactory Paps compared to non-transgender females: implications for cervical cancer screening. J Gen Intern Med. 2014 May;29(5):778–84.
7. Sherbourne Health Centre. Check It Out Guys. 2010 [cited 2016 Mar 10].
8. Vancouver Coastal Health. Binding. Transgender Health Information Program. [cited 2016 Mar 10].