Table 5.

Strategies to facilitate pelvic examination and optimize cervical cancer screening for FTM patients

Before the visit	• Non-discrimination policy on ads and website • Providers listed in WPATH/GLMA directories • Trained staff communicate sensitively when scheduling appointments • Trans-inclusive options on registration forms • Gender identity, preferred name, and pronouns documented in electronic health record
On arrival at the office	• Schedule as first or last appointment, or room patient quickly after check-in • Ask patient for preferred name and pronouns • Presence of brochures, magazines, and posters that are non-gendered and relevant for and/or feature individuals on the FTM spectrum • Non-gendered restroom available
Before the exam	• Ask patient for preferred pronouns and anatomical terms • Take a respectful and adequate sexual history • Apologize immediately for any communication missteps • Offer to review mechanics of the exam with all new patients • Ask patients about prior pelvic exam experiences and assess comfort level and barriers • Discuss options to optimize locus of control (e.g., permit patient to undress only from the waist down, self-insert the speculum, dispense with footrests and/or dorsal lithotomy positioning, discuss how to signal distress or stop the exam) • Discuss exam techniques that will be used to optimize physical comfort (see below) • Consider offering anxiety medication, with caution • Consider suggesting short-course low-dose topical estrogen for patients with past unsatisfactory cytology results • Respect patient preferences regarding provider gender and presence, identity, and gender of a chaperone • Allow patient to decide if and when to proceed with or stop the exam
During the exam	• Use patient’s preferred name, pronouns, and anatomical terms throughout the encounter • Avoid comments about body or genital changes • Use a small speculum, with water-based lubricant and/or topical lidocaine applied to the introitus before speculum insertion • Swab a greater circumference of the cervix than typical and use multiple collection instruments to optimize collection of an adequate sample • Collect samples for cytology and HPV co-testing for all patients aged 30–65 whenever possible • Consider collecting a vaginal swab for primary HPV screening if speculum examination is not possible
After the exam	• Warn about bleeding and offer absorbent products using non-gendered language • Advise on higher prevalence of inadequate tests and potential need to return for retesting • If results are inadequate, use the same 2–4-month guideline for retesting as with cisgender patients • Indicate testosterone use on the cytology requisition • Be prepared to advocate for patient with insurance company if denied coverage • Check that patients who experience distress or discomfort have a post-exam self-care plan in place • Ensure preferred name and pronouns are used when communicating results/performing outreach