Transgender people and sexually transmitted infections (STIs)

Introduction

National guidelines exist on how to take a sexual history and the recommended frequency for sexually transmitted infections (STIs) screening by gender and risk group.[1] The 2015 CDC guidelines 2015 STD Treatment Guidelines do include transgender men and women as special populations, and recommend risk assessment based on current anatomy and sexual behaviors, awareness of symptoms consistent with common STIs, and screening for asymptomatic STIs based on behavioral history and sexual practices.[2] However, these guidelines do not include specific screening or interval recommendations. Presented here are specific considerations when screening for STIs in transgender people. Recommendations for management of confirmed STIs does not differ from those for non-transgender people. Screening intervals should be based on risk, with screening every three months in individuals at high risk (multiple partners, condomless sex, transactional sex/sex work, sex while intoxicated).

In practice, transgender people may avoid screening procedures and physical examinations due to fear of discrimination,[3] encountering providers who are inadequately trained in transgender health,[4] or personal discomfort with the visit or exam.[5] It is important for clinicians to build a trusting and respectful rapport and to clearly explain reasons for asking sexually explicit questions and performing various components of the exam.

Sexual history and risk assessment

Clinicians should assess risk for sexually transmitted infections (STIs) based on the patient's sexual behaviors and current anatomy. Because transgender people differ in hormone use, history of gender affirming surgical procedures, and patterns of sexual behavior, providers should avoid making any assumptions about presence or absence of specific anatomy; sexual orientation; or sexual practices. Anatomy and behavior may change over time; therefore, it will be important to assess for changes that may impact STI risk. To facilitate a respectful rapport, use the patient's internal preferred terminology to refer to anatomic parts.

The Fenway Guide provides suggested sexual risk assessment questions [6] including:

• Are you having sex? How many sex partners have you had in the past year?
• Who are you having sex with? (including anatomy and gender of partners) What types of sex are you having? What parts of your anatomy do you use for sex?
• How do you protect yourself from STIs? (How often do you use condoms/barriers? Any use of PrEP?)
• What STIs have you had in the past, if any? When were you last tested for STIs?
• Has your partner(s) ever been diagnosed with any STIs?
• Do you use alcohol or any drugs when you have sex?
• Do you exchange sex for money, drugs, or a place to stay?

These questions are components of a complete sexual history which would include relationship types, frequency of sexual activity, age of sexual debut, use of drugs or alcohol during sex, sex work history, history of sexual abuse, and sexual function.[7]

Physical exam and STI screening

Serologic screening recommendations for transgender people (HIV, Hepatitis B and C, Syphilis) do not differ in recommendations or technique from those for non-transgender people.

Many transgender people have experienced violence, including sexual violence.[3] Therefore, providers should take a chaperone trauma-informed approach to the exam, whenever possible.[8] This approach is grounded in providing a sense of control to the patient and includes: greeting patients while they are dressed; explaining what you plan to do and why; providing information, choices, and decision-making ability.[9] Some transgender patients may prefer to collect their own specimens to allow for greater control over the screening process. Self-collected vaginal and rectal swabs as well as urine specimens have equivalent sensitivity and specificity to provider-collected samples for nucleic acid amplification testing for gonorrhea, chlamydia, and trichomonas.[1] The physical exam should focus on organs that are present and have the potential for infection based on the sexual history.

Transgender women who have undergone vaginoplasty (either penile inversion or colo-vaginoplasty) do not have a cervix, therefore screening for cervical HPV is not appropriate. Some surgical approaches include the use of urethral tissue, which could result in mucosal infectious such as chlamydia or gonorrhea. The risk of infection of intact, inverted penile skin with these organisms is unknown, though lesions such as a syphilitic chancre, herpes or chancroid are possible. When clinically indicated due to symptoms, a physical examination and appropriate testing should be performed. 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. There is no evidence to guide a decision to perform routine pelvic exams on transgender women in order to screen for such conditions as [formerly penile skin] warts or lesions.

Transgender women who have undergone vaginoplasty retain prostate tissue, therefore infectious prostatitis should be included in the differential diagnoses for sexually active trans women with suggestive symptoms. There is no evidence to guide routine screening for Chlamydia in asymptomatic transgender women who have undergone vaginoplasty, though it is reasonable to consider urinary screening in women with risk factors. The role of vaginal gonorrhea and Chlamydia specimens, as opposed to urine testing only, is unknown in women who have undergone penile inversion. Providers may consider vaginal testing however urine testing should be considered essential.

Pelvic inflammatory disease should be in the differential for transgender men with a uterus and fallopian tubes who have vaginal intercourse. Testosterone use is associated with vaginal atrophy; therefore, use of lubricant and a small speculum may be appropriate for pelvic and speculum exams among transgender men with vaginas. Some transgender men retain patent vaginas after metoidioplasty and may require vaginal screening based on sexual history. Screening for cervical cancer and HPV are covered elsewhere in these guidelines.

References

1. Workowski KA, Bolan GA, Centers for Disease Control and Prevention (CDC). Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep Morb Mortal Wkly Rep Recomm Rep Cent Dis Control. 2015 Jun 5;64(RR-03):1-137.
2. Centers for Disease Control and Prevention (CDC). 2015 STD Treatment Guidelines . [cited 2016 Mar 25].
3. Grant JM, Mottet LA, Tanis J, Harrison J, Herman J, Keisling M. Injustice at every turn: a report of the National Transgender Discrimination Survey . National Center for Transgender Equality and National Gay and Lesbian Task Force; 2011 [cited 2016 Mar 17].
4. Lambda Legal. When Health Care Isn't Caring: Lambda Legal's Survey of Discrimination Against LGBT People with HIV. . New York, NY; 2010 [cited 2016 Mar 25].
5. Bates CK, Carroll N, Potter J. The challenging pelvic examination. J Gen Intern Med. 2011 Jun;26(6):651-7.
6. Gelman M, van Wagenen A, Potter J. Principles for Taking an LGBTQ-Inclusive Health History and Conducting a Culturally Competent Physical Exam. In: Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health. 2nd ed. Philadelphia: American College of Physicians; 2015.
7. Daskalakis DC, Radix A, Mayer G. Sexual Health of LGBTQ People. In: Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health. 2nd ed. Philadelphia: American College of Physicians; 2015.
8. Substance Abuse and Mental Health Services Administration (SAMHSA). Trauma-Informed Approach and Trauma-Specific Interventions . 2015 [cited 2016 Mar 25].
9. Raja S, Hasnain M, Hoersch M, Gove-Yin S, Rajagopalan C. Trauma informed care in medicine: current knowledge and future research directions. Fam Community Health. 2015 Sep;38(3):216-26.