Cervical Screening for Trans and Gender Diverse People

Jun 19
6 min read

Authors: Jacqueline McBratney-Owen, Em Thrower.

Content Warnings: This article discusses cervical screening. When referring to specific parts of the body, we use anatomical/medical terms e.g. cervix, vagina.

A pair of hands holding a swab and a swab container, pulling the swab from the container. The person's sleeves and a counter top are visible in the blurred background, with the focus on their hands and the swab. — *A patient using the self-collection method.*

Anyone with a cervix can develop cervical cancer. The good news is that regular screening can catch high-risk human papillomavirus (HR-HPV; viral strains linked to most cervical cancers) and early cell changes before cancer develops. Because of this, cervical cancer is one of the most preventable cancers.

Trans and gender diverse (trans) people with a cervix are often left out of screening systems due to various social and structural barriers. This blog post is for trans people and their healthcare providers. It explains the basics of HPV and cervical cancer, outlines screening options, discusses trans-specific considerations in cervical screening, and links to research and resources for those who want to learn more.

What is cervical screening and why does it matter?

Globally, HPV infection causes around 5% of all cancers, with HR-HPV present in nearly all cervical cancer cases. HPV vaccination offers the best long-term cervical cancer prevention by stopping new HPV infections, but regular screening for all people with a cervix* is still essential to prevent cases from slipping through the cracks. Screening is designed to detect HR-HPV before cancer develops, or early cell changes that can be treated. A systemic review of seven European studies found that participation in organised cervical screening programmes significantly lowers the risk of dying from cervical cancer.

*Note: Some people may have multiple cervixes (uterus didelphys).

A genderqueer person sitting on a black couch in a medical consultation room, looking at a practitioner who is partly visible in the blurred foreground. They have long, black hair and dark brown eyes, and are wearing a button-down red-and-black flannel shirt with the sleeves rolled up. They have a faint moustache. Their walking cane is resting next to them. — *Genderqueer person talking to a practitioner.* *(Gender Spectrum Collection.)*

Who needs screening?

In Australia, guidelines recommend that anyone with a cervix who has ever been sexually active, aged 25-74 should get a cervical screen every five years if HPV-negative. If HR-HPV is detected, more frequent checks may be needed to watch for early cell changes.

Trans people can be less likely to get automatic screening invites, especially if their health record lists a gender marker other than female (e.g. M or X). If you feel comfortable, it may be a good idea to talk to your healthcare provider about enrolling in the National Cervical Screening Program’s reminder system, or you can set up an automatically repeating reminder in your personal calendar.

If you don’t have a regular healthcare provider, you can still get screened. Local sexual health clinics and community health centres are used to seeing people without a regular doctor. If you’re looking for a provider that understands and affirms you as a trans person, you can find links to directories on our ‘Finding a Doctor’ webpage.

If you’re a trans person who’s had bottom surgery to create a neovagina, we recommend speaking to your doctor or surgeon to create a cancer prevention and STI screening plan based on your specific surgical procedure. How you look after your neovagina will be different to what’s in the general cervical screening guidelines because the cells are different from the cells of a natal cervix, but that doesn’t change the fact that you deserve appropriate, respectful care and tailored prevention strategies.

A pair of practitioner's hands, wearing blue sterile gloves, holding a swab and a swab container, pulling the swab from the container. The practitioner's white sleeves are also visible in the image. In the blurred background, a seated man can be seen, wearing a blue shirt and blue jeans. — *A practitioner showing a swab to a patient.*

What are my screening options?

Traditionally, cervical screening involved a “pap smear” where a clinician collected cells from the cervix directly using a speculum (a tool that holds the vagina open), but there have been some important updates.

In Australia, screening now mostly tests directly for HPV using a vaginal swab, and many people now have the option to self-collect. Self-collection means that you do the swab yourself, without needing a speculum, and people often find it more private and comfortable.

However, if you have any symptoms like unusual discharge, unexplained bleeding (e.g. return of your period despite being on T for a while, bleeding between periods, or post-menopausal bleeding), or unexplained pain in the area, then it's likely you won’t be able to self-collect and will need a clinician to take the swab for you. If you are experiencing these symptoms at any time (even if your cervical screening is not due), you should see a doctor. You can read more about the relationship between menstruation and GAHT in this blog post.

Importantly, you can also opt to have the clinician do the swab for you if that’s your preference, regardless of symptoms.

For more information on accessing screening and self-collection options:

A box of prescribed testosterone in a box, sitting on a wooden table surface indoors. Stickers on the box read, "Testosterone ADVZ 1000, Testosterone undecanoate 1000 mg/4mL, Oily solution for injection, ADVANZ". — *Gender-affirming testosterone undecanoate.*

Does testosterone gender-affirming hormone therapy increase cervical cancer risk?

This is a common question, and the short answer is no. Currently, there is no strong evidence that taking gender-affirming testosterone directly makes someone more or less likely to get cervical cancer. Studies also find that rates of HR-HPV and cytological abnormalities (i.e. suspicious cell changes) in trans people using testosterone and with a cervix are mostly the same as in cisgender women.

Special considerations for people on testosterone

Testosterone is known to cause thinning of the cervical and vaginal lining (epithelial atrophy) and cellular changes (often referred to as ‘genital atrophy’ or ‘genital dryness’). This can make cell samples harder to read and more likely to come back inconclusive meaning the patient may need a repeat test. If someone has been using testosterone, the quality of the cervical screening and the comfort of the person having the test can be improved by topical oestrogen cream, prescribed by their doctor and used before the screen is taken.

Pathologists are also more likely to misinterpret results or declare the sample “unsatisfactory” if they are not aware that the patient is on testosterone, since they don’t have the medical context for why their cells may look different. Therefore, this may be something you want to communicate to the healthcare provider doing the screening, so they can inform the lab that you are on testosterone. This is not strictly necessary to get accurate results, but flagging this with your provider may reduce the likelihood of unnecessary follow-up testing. If you’d like to learn more about genital changes on testosterone, we have a blog post on the topic written by trans healthcare workers and researchers.

Navigating barriers to care

Even though testosterone can affect the diagnostic stage of screening, the main concern is that trans people with a cervix are being screened markedly less often than their cisgender peers due to barriers to care, including:

Exclusion from automatic invitations and results due to a gender marker other than female, such as M or X.
Healthcare workers lacking training on trans health and screening options.
Anticipated stigma, prior negative healthcare experiences, trauma, and gender dysphoria.

However, many of these problems can be addressed. Studies show that HPV self-sampling is popular and effective amongst trans people. Other helpful changes could include making gender-neutral language standard practice in cervical healthcare, sharing relevant medical history (e.g. testosterone use), and training staff in gender-affirming, trauma-informed care.

A trans man sitting in a medical waiting room, holding a clipboard with one hand while he writes on the clipboard's paper with his other hand. He has short, black hair and a black beard with no moustache. He is wearing a blue, collared, button-down shirt. He is frowning with a concerned or focused expression. — *Trans man filling out medical paperwork.* *(Gender Spectrum Collection.)*

How can I prepare?

Not all trans people find cervical screening dysphoria-inducing, but discussions about and examination of the genital area can feel uncomfortable, exposing, or confronting, especially if you’re unsure what to expect. Planning ahead can help you feel more in your control and make your experience smoother.

Bring a support person if you feel this would be helpful.
Ask if self-collection is an option (if you’d prefer this method).
Let your clinician know if you are on testosterone (and potentially the lab too).
Check that you are enrolled in automatic reminders (or set up your own).
If you’ve been on testosterone for a while, or know that you experience physical discomfort with insertion, discuss topical oestrogen with your doctor (using topical oestrogen for this purpose doesn’t cause changes elsewhere in the body or affect your testosterone).
Check out our ‘Finding a Doctor’ webpage for directories to help you find trans-friendly services.

Tips for healthcare providers

Testosterone does not eliminate the risk of cervical cancer, and there is also no evidence that it increases risk.
Offer self-collection as an option for eligible patients.
Patients who have epithelial atrophy or physical discomfort may benefit from a short course of topical oestrogen and may need reassurance about it not affecting their gender affirming hormone therapy or having systemic effects.
Neovaginas do not need standard cervical screening protocols, and have different needs regarding cancer prevention, tissue health, and STI screening.
Discuss patient preferences regarding automatic reminder systems (such as enrolment in the National Cancer Screening Register, or use of self-reminders) and whether they want testosterone use to be disclosed in pathology referrals.
Periodically check with patients that opt to enrol in automatic reminder systems that they a) want to remain enrolled and, if so, b) have not been removed due to a non-female gender marker.
Check in with the person about what language they’re comfortable with, and upskill in trans affirming practice (free training modules can be found here).

The Australian Department of Health, Disability and Aging provides a comprehensive infographic guide on how to approach cervical screening for trans and gender diverse patients.