Enacting power and constructing gender in cervical cancer screening encounters between transmasculine patients and health care providers

Abstract

Transmasculine people are at risk of cervical cancer but have lower rates of cervical cancer screening than cisgender women. Disaffirmation of the patient’s gender and unequal power dynamics between patient and provider during screening contribute to patient unwillingness to be screened. The mechanisms by which the balance of power may be shifted between patient and provider, and by which gender is constructed during the Pap test, are not well understood. A qualitative study using a modified grounded theory approach was undertaken to analyse patient interview and provider interview and focus group data pertaining to power and gender in the context of cervical cancer screening among transmasculine individuals. The study was conducted at an LGBTQ-focussed health centre in Boston, USA. Processes by which power is enacted included constraining or affirming patient choice, mitigating or exacerbating vulnerability, and self-advocacy. Gendering processes included naming patients and their bodies, invoking gender norms, de-gendering/re-gendering Pap tests, and othering or normalising trans bodies. The interplay between these processes promotes or constrains patient agency over body and health, impacting patient care, patient–provider interaction, and service utilisation. Understanding patient and provider roles in power and gender dynamics are critical for the provision of patient-centred care.

Introduction

Transmasculine individuals are people assigned a female sex at birth (AFAB) who identify along a spectrum of masculinity or have a non-binary gender (Reisner, Radix, and Deutsch 2016). Transmasculine individuals engage in a range of sexual behaviours with partners of various sexes and genders and are at risk of human papillomavirus (HPV) and cervical cancer (Reisner et al. 2014; Kenagy and Hsieh 2005; Kenagy 2005). Therefore, medical professional organisations recommend that transmasculine individuals follow the same cervical screening guidelines as cisgender women (i.e. individuals AFAB who identify as women) (American College of Obstetricians and Gynaecologists, 2011). Limited research on cervical cancer prevention among transmasculine individuals shows significantly lower odds of receiving regular Pap tests compared to cisgender women (Peitzmeier et al. 2014; Tabaac et al. 2018). Healthcare providers may perceive transmasculine individuals to be at low risk of cervical cancer and thus not recommend regular screening (Agénor et al. 2016), while patient barriers to screening include physical and emotional vulnerability during the health examination and gender dysphoria (Peitzmeier et al. 2017; Johnson et al. 2016; Hoskin, Blair, and Jenson, 2016; Dutton, Koenig, and Fennie 2008; McDowell et al. 2017).

Power relations between transmasculine individuals and health care providers also likely contribute to lower rates of screening utilisation by transmasculine patients (Poteat, German, and Kerrigan 2013). Power is distributed unequally in patient–provider relationships; providers possess expert knowledge and control access to therapies (Govender and Penn-Kekana 2008; Peppin 1994; von Vogelsang et al. 2016; Nimmon and Stenfors-Hayes 2016; Pauley 2011). Unique factors may affect the power dynamics involved in caring for transgender patients, including unavoidable dependency on the medical system for ‘basic identity expression’ for individuals who seek transition-related affirming care (von Vogelsang et al. 2016; Stroumsa 2014; Spade 2003). Provider bias and discrimination may also reinforce the power of providers in medical encounters with transgender patients (Poteat, German, and Kerrigan 2013); discriminatory provider behaviours include displays of discomfort, denial of services, verbal or physical abuse, and coerced or substandard care (von Vogelsang et al. 2016; Lambda Legal 2012; Kosenko et al. 2013; Bauer et al. 2009). Power relations in the clinical encounter are not fixed, but rather continuously constituted and negotiated (Peppin 1994; von Vogelsang et al. 2016). Preferences for patient–provider communication, including personalisation, authenticity, being informed and ‘treated as equals’, and the creation of a trusting relationship have been emphasised as means to mitigate the patient–provider power differentials in cervical cancer screening among cisgender women (Moore et al. 2000; Armstrong, James, and Dixon-Woods 2012).

In addition to negotiating the balance of power, patient and provider also negotiate and co-construct gender in the clinical encounter (Peitzmeier et al. 2017). Gender affirmation, the multidimensional social process by which an individual is acknowledged in their gender identity, expression, and/or role, is another important dynamic in medical care for transmasculine individuals. Gender-affirming care involves attention to the physical, mental and social health needs of transgender individuals, while respectfully affirming gender identity, e.g. by using correct patient names and pronouns and inclusive medical forms (Reisner, Radix, and Deutsch 2016; Potter et al. 2015). Other best practice information on mitigation of potential gendering processes during clinical encounters, and specifically during gendered medical care like Pap testing, is sparse.

Previous work has used patient interviews to understand barriers or facilitators to cervical cancer screening or has focussed on patient and provider perceptions of whether transmasculine patients were at risk for HPV, using a public health framework (Peitzmeier et al. 2017; Agénor et al. 2016). The current analysis triangulates patient and provider data to elucidate what specific processes patients and providers enact during the cervical cancer screening encounter itself by which power is shifted either toward or away from patients, and by which the patient’s gender is either affirmed or disaffirmed, using a critical lens. Cervical cancer screening requires pelvic examination, which can amplify the dynamics of gender and power that are present to some degree in any clinical encounter, potentially making these processes more visible to study by researchers. Using qualitative data that offers both rich patient and provider input, we develop a theoretical framework to explain how these processes influence cervical cancer screening among transmasculine individuals, an understudied and underserved population.

Methods

Setting

This study was conducted at Fenway Health, an urban health centre in Boston, MA that specialises in the care of sexual and gender minority individuals (Reisner et al. 2015). In 2013, 32 patients completed an in-person, semi-structured in-depth interview. Focus groups (n=3) with healthcare providers (n=15) were conducted, as were two in-depth interviews with providers who could not attend the focus groups. The study was approved by the Fenway Health Institutional Review Board. The study team included transmasculine individuals.

Patient interviews

Eligible individuals were assigned female at birth (AFAB), identified along the transmasculine spectrum, had a cervix and were 21–64 years-old (per US cervical cancer screening guidelines). Because one of the primary aims of the overall study was to understand barriers and facilitators to cervical cancer screening, we purposively sampled for representation from participants who 1) have never had a Pap test, 2) have had a Pap test but screen irregularly, and 3) those who had Pap tests regularly.

Patients were recruited through the health centre, local community-based organisations serving transgender individuals, social media and the 2013 Boston Pride festival. Attempts were made to maximise racial and age diversity by undertaking outreach to social and advocacy groups that focus on older trans individuals and trans people of colour, asking health providers at Fenway Health to inform their trans patients of colour about the study, and slowing recruitment (i.e. not enrolling people on a ‘first-come-first-served’ basis) to allow more time for news about the study to reach diverse communities. Data collection ended after 32 interviews due to achievement of purposive sampling goals around Pap history, maximising demographic diversity to the extent we were able to, and thematic saturation (demographic characteristics found in Table 1).

Table 1.

Patient sociodemographic characteristics.

	In-depth interview participants (n=32)
	n	%
Gender identitya
Male	11	34
FTM/transgender/trans man/trans masculine	22	69
Genderqueer	6	19
Age
Mean age in years (SD; range)	33.3 (10.6; 21–56)
21–29	16	50
30–39	9	28
40–49	2	6
50–59	5	16
Race/ethnicitya
White	25	78
Black/African American/Caribbean	3	9
Hispanic/Latino	1	3
Native American/Alaska Native	1	3
Multiracial	3	9
Educational attainment
High school diploma or GED	1	3
Some college	7	22
College degree	10	31
Some graduate work	5	16
Graduate/Professional	9	28
Annual individual income ($)
Less than 5000	4	13
5000–9999	5	16
10,000–19,999	6	19
20,000–29,999	5	16
30,000–39,999	2	6
40,000–49,999	2	6
50,000 or more	7	22
Refuse to answer	1	3
Gender(s) of sexual partners (past 12 months)a
Cisgender women	17	53
Transgender women	2	6
Cisgender men	7	22
Transgender men	7	22
Other (non-binary, genderqueer, etc.)	2	6
Ever used testosterone
Yes	30	94
No	2	6
Received surgery for gender affirmation
Yes	15	47
No	17	53

^aMultiple responses/selections allowed; will not equal 100%.

The semi-structured interview guide addressed transmasculine individuals’ perceptions of HPV and cervical cancer risk and prevention, experiences obtaining a Pap test, interactions with providers, access to health information and gender dysphoria in the context of cervical cancer screening. After obtaining written informed consent, in-depth interviews were conducted in a private room at Fenway Health. Interviews were conducted in English, audio-recorded and lasted between 60 and 125 minutes (average = 93 minutes). Participants then completed an anonymous sociodemographic questionnaire and received US$50 for their time and travel.

Interview recordings were transcribed verbatim and entered into ATLAS.ti version 7.¹ Data analysis was guided by principles of grounded theory (Charmaz 2006). Transcripts were coded line-by-line, followed by a focussed approach using a codebook comprised of inductively derived codes. Coders met several times to discuss coding decisions, reconcile discrepancies and revise the codebook. The team developed categories using axial coding and formulated themes comprised of multiple categories, a process facilitated by writing memos and discussions. These themes were abstracted into the theoretical framework presented here (Charmaz 2006).

Healthcare provider focus groups & interviews

Eligible healthcare providers possessed an advanced nursing or medical degree and had performed at least one Pap test on a transmasculine individual. Maximum variation sampling ensured the inclusion of providers from various professional backgrounds and practice settings. Providers were recruited via the health centre, referral from patient and provider participants and from local World Professional Association for Transgender Health listings (Table 2).

Table 2.

Healthcare provider sociodemographic and professional characteristics (n=17).

	N	%
Gender identity
Cisgender woman	13	77
Cisgender man	4	24
Professional background
Physician	11	65
Nurse practitioner	4	24
Physician assistant	2	12
Practice setting
Hospital	5	29
University	1	6
Fenway Health	10	59
Another community health centre	1	6

The provider interview guide focussed on clinicians’ perceptions of HPV and cervical cancer risk and prevention among transmasculine individuals, as well as provider experiences and recommendations for providing Pap tests to transmasculine patients. After obtaining written informed consent, provider focus groups and in-depth interviews were conducted in a private room at the health centre and a nearby hospital. Interviews and focus groups were conducted in English, were audio-recorded and lasted 60minutes.²

The focus group audio-recordings were transcribed verbatim and entered into ATLAS.ti. Provider transcripts were analysed using a codebook of deductive codes, which was based on the provider focus group guide and developed in consultation with other members of the team. Compared to the more wide-ranging in-depth interviews with patients, provider focus groups rarely strayed from the specific questions posed about clinical care of transmasculine patients, and therefore a deductive codebook was deemed adequate for analysis. The codebook was then applied by a team of coders to all of the provider focus groups and interviews. Discussion and memoing was used to then move from codes to theory. Peer debriefing was used to refine the initial drafts.

Results

Transmasculine patients and their providers engage in processes that either reinforce or challenge the unequal balance of power with which they enter the interaction, which we collectively labelled enacting power. These processes included affirming or constraining patient choice (provider protecting ongoing and freely given consent for a Pap, versus medical gatekeeping to coerce a Pap), mitigating or exacerbating vulnerability (provider recognition of the invasiveness of the Pap test and acting to minimise it, versus refusing to make modifications or heightening scrutiny of patient bodies), and self-advocacy (patient demanding what is needed versus leaving needs unspoken).

While the patient walks into the cervical cancer screening encounter with a certain internal gender identity, in the interaction between patient and provider, several processes may serve to either affirm or disaffirm that identity, which we collectively label constructing gender. Those processes include naming patients and their bodies (using name, pronouns, and names of body parts desired by the patient, or not), de-/re-gendering Pap tests (radical reconceptualisation of the Pap as masculine or gender-neutral, versus reinforcing feminine framing of Pap tests), invoking gender norms (masculine or neutral norms of interaction versus feminine norms), and normalising or othering transgender bodies (Figure 1).

Figure 1.

Enacting power and constructing gender: A grounded theory of how patients and providers interact in in a cervical cancer screening encounter to produce patient (dis)empowerment and gender (dis)affirmation, and accordingly, a therapeutic alliance that does or does not support the patient decision to undergo cervical cancer screening.

Because the health provider enters the encounter with the balance of power, four of these seven processes are primarily provider-driven and two are often driven by both patient and provider, while one is primarily patient-driven. However, all processes take place within the interaction between patient and provider, and the patient is not powerless or passive in any process. These processes of enacting power and constructing gender are intertwined, with disaffirmation placing the health provider in opposition to the patient and asserting provider authority over patient identity, body and agency, in effect asserting that the provider is the one that should have the power to define the patient’s gender. In contrast, shifting the balance of power toward the patient creates more space for the patient to express their gender and be affirmed in it. When all these processes are enacted in such a way that on the balance, the patient is empowered and their gender is affirmed, a positive therapeutic alliance is created between patient and provider that promotes empowered utilisation of cervical cancer screening. Alternately, when the patient is disempowered or their gender is disaffirmed, this entrenches negative power differentials between patient and provider and leads to either no or coerced utilisation of cervical cancer screening. Empowering care experiences are associated with enhanced feelings of safety, capacity for self-advocacy, and reduction in dysphoria-related distress, whereas disempowering interactions induced feelings of violation, severe emotional distress and persistent distrust of providers.

Enacting power

Affirming or constraining patient choice

Transmasculine patients must obtain provider approval for transition-related care, such as gender-affirming hormones. The gatekeeper role gives health providers not only the power to regulate transmasculine bodies in accordance with their conception of transgender identity, but also grants undue power when negotiating other aspects of care.

I think being um, the hormone and the primary care provider, I have a little bit more like, capital to spend with patients because I kind of control - as messed up as the power dynamic is - I sort of like control their hormone prescription, and so I think people are more willing to come back and see me than if I were just like some random GYN person who was saying, ‘You should do this’. (Beth; Cisgender woman, Primary Care, Nurse Practitioner, 5 years in practice)

Though acknowledging it as ‘messed up,’ this provider perceived the consequence of this power imbalance, i.e. the greater likelihood of patient follow-up with transition care providers, to be beneficial. However, this exertion of authority has the potential to undermine patient agency, coerce consent for screening, and distort the patient–provider relationship. Multiple transmasculine participants believed that cervical cancer screening was required in order to receive testosterone therapy. The intentional or unintentional pressure to undergo a Pap test, which for some participants was perceived to be invasive and even traumatising, resulted in patient disempowerment and constrained decision-making. Several providers sought to preserve patient agency over body and identity by affirming that transition-related care was not contingent on preventive sexual health care or cervical cancer screening, and explicitly stating that they do not have power over the patient:

“We’re not doing it today, we’ll come back to it. Maybe at some point you’ll be ready, and maybe you won’t.” I said, “I’m not here- I’m not here to assault you about this, you know, this is- this is your health, and you know, we’re working together, and if you tell me…not to do something, I just document we’re not doing that.” (Harry; Cisgender male, family practice, 25 years)

Particularly important to maintaining patient agency throughout the encounter was establishing informed consent as an ongoing process that could be revoked at any time.

I always throw in a ‘You’re in charge’, because I think that makes the patient kinda feel like, okay, this isn’t something now that’s being taken out of my command. So always say, ‘You’re in charge, at any point, if you’d like for us to stop…then you let us know, and that’s what will happen’, before I even put my hands on the patient. (Andrea; Cisgender woman, Infectious Disease, Physician, 10 years in practice)

Unfortunately, several transmasculine participants reported experiences with providers who exerted control by failing to obtain informed consent or to comply with patient requests, including instances during which the provider ignored complaints of pain and/or calls for the exam to stop. These experiences of extreme violation left participants feeling dehumanised with several likening the non-consensual examination to rape.

It was just no matter I told her, like, ‘I need you to go slowly, or I need you to like give me like a second to like, catch my breath before you do something’, she would just kinda like, ‘oh, well, whatever’. Like, kinda just waved me off and just like, ‘I’m the doctor, I know what I’m doing. I’ve practised on cadavers and whatever’. (Alex; Male, 26 years)

Mitigating or exacerbating vulnerability

Health providers’ interactions with the patient’s body, both through physical touch and verbal communication during the encounter, profoundly affected a patient’s sense of vulnerability. Most patient participants considered the speculum examination to be an ‘invasive’ procedure (Alex; Male, 26 years). Nudity and being in the lithotomy position, in addition to speculum placement and the Pap test itself, were all identified as factors contributing to the invasiveness of the examination. Many providers recognised the potential for patient vulnerability and used a variety of strategies, including encouraging patients to bring a support person, use alternate positions without stirrups, and even self-inserting the speculum to mitigate the invasiveness of the procedure (Potter et al. 2015).

I think in a doctor-patient situation, sometimes - and I can’t imagine it because I’ve been who I am for so long - but there’s this power differential, and so, if they’re getting up into some really vulnerable position in the stirrups, then that’s pretty scary because what if somebody does something to them that they don’t want? And so, I make sure that patients never feel that they’re going to be coerced, or anything will happen, that they’re in complete control of the situation at all times. (Sam; Cisgender woman, Family Medicine, Physician, 20 years in practice)

However, sometimes even these same providers simultaneously acted in ways that could exacerbate vulnerability. Patients allowed providers to interact with their body because they believed a provider’s motivation for doing so was purely medical and non-judgemental. When providers instead referenced patient bodies in casual or non-scientific ways (e.g. ‘pudgy’, ‘manly-looking legs’), transmasculine participants felt on display and violated. Commentary on medically irrelevant characteristics of the patient’s exposed body during the examination, such as tattoos and genital piercings, also increased feelings of scrutiny and non-neutral evaluation. Several transmasculine participants also felt dehumanised if the Pap test was performed in a ‘perfunctory’ or ‘transactional’ manner. One participant noted that the experience made him feel like ‘just another vagina walking in the door’. (Forrest; Trans/FTM, 51 years)

Self-advocacy

Because the balance of power when a patient and a provider enter a room rests with the provider, the processes to shift power identified above – to either share power with the patient or to entrench the power differential – are primarily provider-driven. However, self-advocacy allowed patients to exert control over the processes described above and resist potential gender disaffirmation and disempowerment in the clinical encounter by actively expressing their needs and refusing care that was undesired or unaffirming. Key features influencing patient capacity for self-advocacy included level of self-affirmation in their gender, intersecting experiences of oppression and privilege and history of trauma.

Transmasculine participants described varying levels of self-affirmation and an internal sense of validation of gendered self and self-actualisation, often linked their ability to externalise rather than internalise discrimination or gender disaffirming interactions to their personal security in their gender identity. For many, the actualisation of medical, legal and social transition goals facilitated self-affirmation, and therefore their ability to advocate for themselves in clinical and other settings.

I know for me earlier in transition, you know, before I started T, before I changed my name, I was a lot less confident in who I was …. But, you know, after starting T, and my body looking more like how I wanted to look and you know, for my name to be how I wanted to be…the further along I’ve come, the more confidence I’ve had, the more I’m able to speak out, and just be like ‘Look, you’re pissing me off. You’re wrong. This is how I need you to talk to me. This is how I need you to interact with me’. (Glen; Male, FTM, 21 years)

Several participants in this majority white and college-educated cohort also perceived that privileged parts of their identities granted them greater respect from providers and therefore greater agency in health care settings, particularly by being treated with respect and thus granted power in comparison to transmasculine people of colour. One participant who had graduated from college explained:

I’ve had a very interesting experience as a trans guy, which I feel like I have a very specific privilege with doctors… Like, you know, when you’re a patient and just like, you know what you want, you know who you are, and you’re like, professionally successful, doctors tend to give you a little bit more respect than I think is deserved ….It makes me a little bit nervous for the people who don’t feel the same way, I don’t want them to be like, in a place where just like, their authority over self is diminished because their life is, you know, they haven’t gotten things together the same way. (Jason; Male, 24 years)

Trauma history also influenced participants’ perceived ability to advocate for themselves during physical exams such as Pap tests. One participant who had never received a Pap explained:

I have a history of being abused, so I really like when people ask me every step if it’s okay and not just go barrelling on…[I have] difficulty with the idea of, you know, telling somebody, ‘hey hold up, stop this a second’, or you know, ‘hey, fuck off we need to stop this’. (Lee; Male, 27 years)

Constructing gender

Cervical cancer screening is not just a medical encounter, but also a social interaction in which gender is co-constructed by the patient and provider (Peitzmeier et al. 2017). When the balance of power is skewed toward the provider due to the processes of enacting power described above, the patient has less power to self-determine gender. The provider and patient contribute to processes that construct gender in the clinical encounter, including naming the patient and their bodies, invoking gender norms, de-/re-gendering the Pap test, and othering or normalising transgender bodies.

Naming patients and their bodies

The words used to identify the patient and their body parts not only explicitly gender the patient, but also assert who has the power and right to do this naming. The process of naming begins even before the start of the clinical encounter, with patient forms that may or may not use inclusive language about gender identity and naming, making patients literally unable to name themselves. Some participants stressed that providers honouring ‘some of the most basic information’ about them (Joe; Male with ‘complicated bits’, 34 years) strengthened the therapeutic relationship.

What’s even worse is when you introduce yourself, if they know your legal name, even if they’re getting the name right, they’re messing up the pronouns all the time. Like, no, no I gave you my name, I’m presenting to you with, you know, a bristly crop of facial hair, this should not be difficult for you (Lee; Male, 27 years).

The anatomical terminology used during the visit maps gender onto the patient’s body and may align with or undermine the patient’s identity. Language used by providers without assessing patient preferences signalled to transmasculine participants how their gender identity was perceived. Most transmasculine participants wanted their provider to use alternative terms for body parts that were either masculine or gender-neutral (e.g. ‘inside’ or ‘canal’ versus ‘vagina’). Several participants used the naming process to differentiate their bodies from those of cisgender women and assert a masculine body and identity to their provider:

One time, [my doctor] referred to my, um, body, and she was referring to a specific part of my body, and she said, ‘your clitoris’. I don’t use that name, and I totally understand why it’s hard for someone to not use that name, because they’re just thinking, ‘This is the name of that thing, why would I call it something different?’ Right? But, like, to me, it’s like a matter of like, well, this is the way that you have been taught that a female body is, and this is what this part of a female body is. The reality is, a guy like me starts thinking, alright, well I have somethin’ different, because first of all, I have somethin’ different because of the way I think about my gender identity, second of all, hormones are changing the way my body is, I don’t actually have a traditionally female body anymore, so why should you treat it that way? (Jason; Male, 24 years)

Invoking gender norms

Beyond explicitly naming patients and their body parts to gender them, other cues more subtly invoked traditionally masculine or feminine gender norms to gender the patient. Transmasculine participants distinguished between being treated generally ‘like a woman’ or ‘like a guy’ during the encounter based on the gender stereotypes perpetuated by providers via verbal and nonverbal communication. For example, providers signalled that they perceived their transmasculine patients as women by referencing stereotypic female undergarments:

When I like got the paper gown on I was so nervous I couldn’t take off my underwear and I was wearing briefs which were very obviously, very clearly briefs, and she like, just casually, like as I’m like getting set up and everything she’s like ‘Okay, can you like take your panties off now?’ (Alex; Male, 26 years)

Communication style could also feel masculinising or feminising. One participant juxtaposed condescending tones and use of terms of endearment like ‘dear’ that are used in stereotypic communication with women to his preference for being addressed ‘matter-of-factly’ (Terry; Man, 53 years). Firm handshakes and emotional restraint were other normative masculine exchanges that some perceived as gender-affirming, with the caveat that exaggerated performances of masculinity by cisgender men providers could seem inauthentic.

The physical environment was another means of signalling gender for patients, particularly in gynaecology-specific clinics. In addition to the presence of predominantly feminine-presenting individuals, socially feminine décor and health education materials in examination and waiting rooms that cater to cisgender women delineate clinics as ‘women’s spaces’. (Joe; Male with ‘complicated bits’, 34 years)

I have definitely felt pretty out of place in waiting rooms of some, ah, you know some gynaecologists because…there are ladies, ladies, ladies…me!. I think it’s better for everybody else if trans dudes can have a Pap smear in a gender neutral environment. (Joe; Male with ‘complicated bits’, 34 years)

De-gendering/re-gendering Pap tests

The Pap test is unlike other medical encounters such as taking a blood pressure, because patient and provider are negotiating power and constructing gender within a framework – the ‘well women’s examination’ – that is already heavily feminised. The conflation of female gender with the focus on certain body parts, including vaginas and cervices, was identified as a powerful means of gender disaffirmation that health providers, patients and clinical settings either perpetuated or resisted. With their cognitive processes and actions, patients and providers could either reify this sense of the encounter (and by extension, the patient) as feminine, or they could resist this feminisation by de-gendering or re-gendering the Pap test itself as gender-neutral or masculine. Cognitive processes to resist feminisation of the Pap test went beyond relatively easy-to-implement ‘best practices’ (like asking the patient for their gender, name and pronouns) and required the patient and provider to fundamentally reconceptualise the Pap test. When this reconceptualisation failed, full affirmation of the patient’s gender could not be achieved.

Transmasculine participants used different strategies to reject the Pap test as an inherently female experience because of the body parts under examination (Peitzmeier et al. 2017). Some transmasculine participants re-gendered their body parts in accordance with their self-identified gender and claimed Pap tests as a masculine experience or ‘this other way of being a guy’ (Ollie; Trans guy (FTM/genderqueer), 38 years). Others used gender-neutral focus on ‘parts’, using metaphors about how cars or machines need maintenance according to their mechanic components. For providers, efforts to conceptualise cervical cancer screening as gender-neutral included generalising the experience to all genders or removing all reference to gender, often by focussing on aspects of pathophysiology and preventive health.

Participant 1: [Hana; Cisgender woman, Internal Medicine, Physician, 5 years in practice]: I think explaining to the patient…that you don’t get [the Pap] just because you’re a woman, it’s because if you have been exposed to HPV and if you have a cervix, that’s what we’re looking for… when you remove the whole gender, it’s not something that girls do, it’s something that people with cervixes do, then, um, I think that’s really helpful… I hardly ever say “cervical cancer”, I just say “cancer”. I try to keep things as gender-neutral about like, your anatomy and things saying, “Well you know, you can get cancer, you don’t have to have, you know, the virus moves on mucosa, and it can be in anal or penile or you know, whatever, but I try not to say as many female anatomy words.

Participant 2: [Carl; Cisgender man, paediatrics, 10 years]: Yeah. I just focus on, it’s about cancer. It’s cancer prevention, it’s just a screening technique.

However, some providers insisted the Pap was quintessentially, inalterably feminine and rejected reframing cervical cancer screening as gender neutral or masculine. For these providers, even inanimate specula took on a feminine gender via their connection to the Pap test:

Moderator: What strategies do you use to try to make the Pap test, the gynaecological exam more a male test or a more gender-neutral test? [Multiple participants laugh]

Participant 1: [Hans; cisgender man, reproductive endocrinologist, 25 years in practice]: I don’t think you can! I mean, it’s a Pap smear….

Participant 2: [Sarah; cisgender woman, Ob/gyn, 5 years in practice]: I don’t even think I understand what that means to make it more male-friendly, like –

Participant 3: [Natasha; cisgender woman, infectious disease, 15 years in practice]: There’s no way- [Multiple participants laugh]

P1: There’s no way [Multiple participants: Yeah]

P3: That’s the bottom line.

Participant 4: [Lisa; cisgender woman, ob/gyn, 30 years in practice]: There’s no manly speculum… It just doesn’t – [chuckles] incongruent

P3: In fact, men who come for anal Pap smear, I say like, “Oh, it’s just like women getting Pap smears, you know, 1 to 3 years, you have to do it for men who have sex with men”, you know. [Multiple participants: Yeah]

Othering or normalising transgender bodies

Unique access to health knowledge grants health providers the authority to delineate what is abnormal versus normal about human bodies. Transmasculine participants described an acute awareness of being othered and marked as different in the clinical encounter, particularly in the context of anatomical changes due to testosterone therapy.

Provider cues that could augment patient feelings of difference included general demeanour and reactions to the patient’s body, as well as stigmatising or discriminatory behaviours. Transmasculine participants were more likely to feel like a ‘medical oddity’ if the provider was not familiar with transmasculine patients. (Lee; Male, 27 years). This othering was not only an assertion of power by the provider to mark what is abnormal but could also destabilise the patient’s gender and even their sense of self (Peitzmeier et al. 2017).

I will say for a medical student, she was phenomenal about it, and I could really tell like, was trying to check herself. But it was still like, okay, I feel like I’m on show right now…You could tell she was taking it all in a very respectful way, but it was still like a surprise, and still, um, understand again about that point of difference, that if I were someone who was cismale and getting any sort of regular check-up this wouldn’t be a surprise to you. (Aiden; Genderqueer FtM, 25 years)

Discussion

Our theoretical framework details the processes by which power is enacted and gender is constructed between healthcare providers and transmasculine patients during clinical interactions, especially gendered interactions such as the Pap test. Power enactment and gender construction influence the patient–provider therapeutic alliance to impact health outcomes. This framework builds on previous work exploring transgender patient–provider power dynamics and stigma, by further elucidating the mechanisms by which power relations are created and reinforced, as well as how gender is constructed in the context of gendered medical encounters (Poteat, German, and Kerrigan 2013).

In this study, the mechanisms by which patients and providers enacted power and constructed gender worked directly to strengthen (or weaken) the therapeutic alliance and promote (or undermine) screening adherence. These processes were inherently intertwined: one of the strongest ways to enact power in a cervical cancer screening encounter with a transmasculine individual is to claim the right to define gender. In parallel, perhaps the best way to construct gender in the encounter is to empower patients to self-identify. If the patient and provider together succeed in affirming patient gender, the patient gains the power of autonomy, the provider gains the power of trust, and a stronger therapeutic alliance emerges.

It is particularly challenging to achieve patient empowerment and gender affirmation in the cervical screening encounter because at the outset, the default power dynamic is affected by systematic cisnormativity and the authority ascribed to providers (Goodyear-Smith and Buetow 2001), while the default gender is skewed feminine due to societal conceptualisations of the Pap text as feminine. The potential for the initial power imbalance to beget further patient disempowerment was also identified during cervical cancer screening: several participants felt coerced to undergo an invasive examination due to the belief that receipt of gender affirming therapy was contingent on cervical cancer screening specifically (Pauley 2011; Peitzmeier et al. 2017). Because of these factors, providers offering Pap tests to transmasculine patients require a particularly high degree of self-awareness and commitment to affirming and empowering patients.

Many provider participants displayed an inability to reconsider the gendered nature of transmasculine bodies in the context of performing the ‘feminised’ Pap test. These providers believed that Pap tests were naturally and inextricably linked to femininity, when in fact an extensive amount of unseen effort is required to maintain the ‘womanliness’ of reproductive and sexual health involving vaginas, cervices and uteri. Most blatant is the replacement of ‘patient’ in forms, brochures and speech with the word ‘woman’ and the use of pastel and floral décor in ‘women’s health clinics’. The feminisation of gynaecology practices and health spaces generally constitutes and sustains the conception of cervical cancer screening as ‘women’s health’ and by extension, patients as women.

Implications for clinical practice

Study findings have important implications for how best to promote patient agency and comfort. We urge health and other service providers to reject the assertion that cervical cancer screening and reproductive organs are inherently feminine, and to pursue self-awareness of the processes that gender both the patient and the exam. Assumptions about the patient must be avoided to circumvent imposing gender constructs and stereotypes that do not align with the patient’s gender (or any other) identity. Clinicians should also take care to avoid terms of endearment or condescending tones, which any patient may find uncomfortable.

A focus on ‘women’s health’, as demonstrated by the terminology used to describe body parts and clinical settings promoting a hyperfeminised environment, is not only gender-disaffirming, but explicitly excludes masculine-presenting people from accessing cervical cancer screening. Patient decision-making may also benefit from an emphasis on cancer prevention and the pathophysiological importance of cervical cancer screening (Potter et al. 2015), versus perpetuating the idea that Pap tests are something ‘women have to do’.

Pre-examination counselling can emphasise patient control over whether to proceed with a Pap test, the role of ongoing consent, and the fact that transition-related care will not be affected by preventive care decisions. If a patient initially declines testing, a provider can respect their agency by asking permission to revisit the topic at future visits. Additionally, interventions to address past patient experiences of oppression, trauma and efforts to promote patient self-affirmation and resilience are vital to promote patient autonomy and comfort during cervical cancer screening as well as in other clinical interactions.

Study limitations

First, the lack of racial/ethnic and class diversity of patient participants may limit the relevance of our findings for transmasculine individuals of colour and those from lower socioeconomic backgrounds. As transgender people of colour and/or low-income face greater discrimination and lack of access to healthcare, research that inadequately addresses the intersectional experiences of transmasculine individuals may perpetuate inequities (Stroumsa 2014). Second, our health provider participant sample was small and consisted mostly of the employees of the health centre who had the most experience working with trans patients and worked in a comparatively trans-affirming environment. Third, provider focus group participants shared fewer details of internal processes and experiences of emotional vulnerability and discomfort compared to the two in-depth interviews with health providers who could not attend the focus group, which limited analysis of the provider perspective. Provider responses may have been skewed towards positive experiences due to reticence discussing sensitive topics in the presence of colleagues.

Future studies on the experiences of transmasculine individuals of diverse backgrounds are needed to inform the development of evidence-based guidelines to promote access to affirming cervical cancer screening. Such research may identify sources of intra-community disparities. Provider internal cognitive processes that may contribute to disempowering and gender-disaffirming behaviours need to be better understood. Such an understanding may help inform provider education and training. The development of evidence-based patient, provider and systems-level interventions addressing barriers to patient-centred cervical cancer screening for transmasculine individuals are also needed. Examples of such interventions include patient tailoring (e.g. asking patients which anatomical terms they use, allowing patients to bring a chaperone or listen to music during examinations), provider education regarding pronouns and taking inclusive sexual histories, as well as system-level changes such as inclusion of a non-discrimination policy on clinic websites (Potter et al. 2015).

Conclusions

Gender-affirming and patient-empowering processes that occur during cervical cancer screening, as well as other care for transmasculine individuals, have a profound impact on patient experiences, patient–provider relationships and health care utilisation. Disaffirming, disempowering care poses a barrier to fulfilling the basic, universal need for healthcare that is safe, dignified and free from coercion (Hagen and Galupo 2014). An understanding of both patient and provider roles in power enactment and gender construction is critical to the provision of patient-centred care and is crucial to the development of a strong therapeutic alliance (Goodyear-Smith and Buetow 2001; Scholl et al. 2014; Mead and Bower 2000; Rathert, Wyrwich, and Boren 2013). As processes of power and control are at play in every clinical encounter, power and gender analyses provide a useful framework to assess and improve care for all patients.