At a preventive cancer screening, transmasculine people may now quite literally take matters into their own hands. A 2018 study found that transmasculine people prefer self-swabbing over having a provider collect a cervical-cell sample as part of routine cervical-cancer screening. The study also added more proof to the growing body of work examining the efficacy of human papillomavirus (HPV) DNA testing as a proxy test for cervical cancer, over the traditional Pap test.
Sari L. Reisner, Sc.D., led the study’s research team through the Trans Masculine Sexual Health Collaborative at Fenway Health, a Boston-based LGBTQ-focused clinic. Their study is the first study to focus on HPV testing and cervical cancer screening of transmasculine people.
When asked how HPV and cervical cancer became a research priority, Reisner looked to personal experience and professional expertise.
“The struggle with cervical cancer screening is very real for transmasculine people,” Reisner told TheBodyPro. “As a member of the transmasculine community myself, I had always heard [about] and discussed this struggle with friends and community members.”
In 2012, Reisner and the Fenway Health team began looking for answers. In examining current patient records, they found that 36% of transmasculine patients were not up-to-date with cervical-cancer screening based on existing—albeit non-inclusive—guidelines. This alarmed Reisner, who hypothesized that the screening rates for people accessing care at non-LGBTQ clinics were likely higher.
HPV is the most common sexually transmitted infection (STI) in the United States, and it is made up of about 200 different types. While the HPV strains that cause genital warts are considered low-risk in terms of causing long-term disease, at least a dozen types of high-risk HPV cause the majority of HPV-related cancers, including cervical cancer.
While HPV is clearly an issue for the vast majority of people, transmasculine people face an array of barriers when understanding their HPV risk and accessing cervical-cancer screenings. These may include:
- Provider discrimination: Past experiences of provider discrimination or the threat of discrimination may result in delaying or avoiding care.
- Inadequate Pap tests: Transmasculine people are 10 times more likely than cisgender women to have had an inadequate Pap smear, one of the most utilized cervical cancer screening methods.
- Gendered spaces: Screenings are often located in sex-segregated spaces, like OB/GYN offices and “women’s” health clinics. Patients may be misgendered or have parts of their body described with gendered terminology.
- Dysphoria and discomfort: Gender dysphoria around genitals and pelvic or gynecological health may prevent transmasculine people from requesting or completing screening.
- Sexual violence: Histories of sexual abuse, assault, and trauma may make it difficult to receive a pelvic exam.
- Insurance exclusions: Health insurance often won’t cover sex-specific services (like Pap smears) if someone’s gender marker is listed as “male.”
- Invisibility in screening guidelines: When discussing cervical cancer, institutions often default to using the term “woman” rather than “person with a cervix.” Cervical cancer screening recommendations from the U.S. Preventive Services Task Force, the Centers for Disease Control and Prevention, and the American College of Obstetricians and Gynecologists say nothing about transmasculine people.
Taking those barriers into account, this study focused on two core areas: first, to determine the efficacy of self-swabbing versus the “gold standard” (i.e., provider-collected swabs in transmasculine people); and second, to see if self-swabbing might be a more affirming, comfortable, and acceptable option for transmasculine people to complete preventive cancer screenings.
Participants attended a study visit that included answering survey questions about past HPV-related experiences, taking a self-collected swab for high-risk HPV (hrHPV) DNA, receiving a provider-collected swab for hrHPV DNA, and completing a brief interview about their testing experience. Both of their swab samples were analyzed using hrHPV DNA testing, a proxy for cervical-cancer detection.
A Note on Cervical Cancer Screening Techniques
The Pap smear has been considered the historical “gold standard” of cervical-cancer screening. Using a speculum enables a provider to access the cervix and scrape off cervical cells to test for precancerous abnormalities. This process is called cytological screening and relies on visual observations of cervical cell samples through a microscope.
However, hrHPV DNA testing has proven to be a more sensitive screening tool. It can determine potential cancer outcomes by testing the HPV DNA to determine the presence of high-risk types of the virus. In this study, provider-collected swabs used cervical cell samples for hrHPV; patient-collected swabs used vaginal cells, since reaching the cervix is difficult in self-swabbing. HPV DNA testing can be done alongside Pap smears in certain cases, using the same sample of cervical cells.
Of the 131 participants who completed both test options, the provider-collected cervical swab detected 21 cases of hrHPV. The self-collected swab detected 15 cases. In comparison to the “gold standard” provider-collected swab, self-swabbing demonstrated a 71.4% sensitivity (to correctly identify those with hrHPV) and a 98.2% specificity (to correctly identify those without hrHPV). These results aligned with those from existing self-swabbing test performance studies among cisgender women with cervices.
Regardless of the efficacy, the participants were united in their preference: Over 90% endorsed self-swabbing over provider-collected methods.
However, screening location mattered to those who endorsed the method. Most of the participants said that they were comfortable with a provider-administered Pap test, but only at a transgender-affirming clinic like Fenway Health. When participants didn’t have the option to go to an affirming health provider, they opted for the self-swab method.
Reisner summarized this key distinction, saying, “This underscores that not only is it important to explore less invasive and more patient-centered means of cervical-cancer screening, but also how important provider education is in creating a multifaceted approach to [close] the gap in preventive cervical-cancer screening disparities for transmasculine people.”
Study participants who preferred to not self-swab cited discomfort around touching their pelvic area and worrying that they wouldn’t perform the self-swab properly, leading to invalid results.
Past research on self-swabbing for cervical-cancer screening with cisgender women demonstrates that offering a self-swab option increases cancer screenings overall. For transmasculine people, having a less invasive screening option that allows them to choose what works best for them and their bodies is critical to increasing screening rates in this community.
“Patients who would otherwise refuse to do any form of cervical-cancer screening because of gender dysphoria or fear of interacting with a provider or another reason may consider doing so,” Reisner said.
For transmasculine people living with HIV, these routine HPV-related cancer screenings can be lifesaving. The National LGBT Cancer Network found that people living with HIV are at higher risk for HPV infection and cancer outcomes, including cervical, vulval, penile, and anal cancers. International research shows that cervical cancer is five times more likely to become a reality for people living with HIV than those not living with HIV.
While this study has clear implications for improving cervical cancer screenings, it also provides a vision for offering affirming HIV and STI testing options, as well as bettering pelvic and sexual health care for transmasculine people overall.
Demonstrating the acceptability of self-swabbing in this study broadens the opportunity to provide the same tool as a routine option in HIV, STI, and other sexual health testing efforts. Patient self-swabbing for chlamydia, gonorrhea, and other bacterial infections is an option in some U.S. states; however, the options frequently vary by state, clinic, and provider preference.
Enabling patient autonomy by providing transparent options like the self-swab is a step in improving the quality of sexual and pelvic health care for transmasculine people.
Fenway Health released a guide on HPV and cancer for transmasculine people in 2014, just two years after Reisner’s team began their investigations into screening disparities. Among detailed background information about the virus, the guide provides a checklist for patients so they can feel more in control of their pelvic exam. Affirming that transmasculine patients have control over how their exam can be made more comfortable is key in further reducing these disparities.
When asked how providers can play a role, Reisner affirmed that not making assumptions is key. Transmasculine people have different needs, especially when it comes to health care. “Clinicians should have a conversation with the patient about the pros and cons of each option and identify a way forward together,” Reisner concluded.
Support and transparency paired with options like self-swabbing can affirm patients’ autonomy over their bodies, enabling them to get screened however works best for them.