Barriers to cervical screening for trans men and/or non-binary people

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The information on this page is for reception staff and clinical staff who may have trans men and/or non-binary people as patients now or in the future.

It aims to explain some specific barriers to cervical screening for the community and offer tips to help you better support them.

See all our resources on this topic >

On this page:

Invitations >
Disclosure >
Negative or inappropriate reactions >
Misgendering and using incorrect language >
Dysphoria >
Testosterone replacement therapy >
Incorrect sample processing >
Further support >

Want to know more about the language we use on this page? Visit our glossary >

Cervical screening for trans men and/or non-binary people

Accessing cervical screening in an environment where they feel safe and in control can be difficult for many people. This can be exacerbated for trans men and/or non-binary people with a cervix who face many barriers to accessing routine cervical screening, as well as discrimination because of their gender identity.

It is impossible to understate the importance of the sample taker and other staff, especially your relationship with the patient, in overcoming these barriers. You may be the difference between someone feeling able to go to cervical screening or not attending.

Invitations

Only people who are registered as female with a GP surgery are invited for cervical screening via the call and recall system. This means that trans men and/or non-binary people who are not registered as female but do have a cervix need primary care professionals to engage with them in an understanding and supportive way. We discuss how you can do that below.

Disclosure

Disclosure means making something new or previously unknown known.

If a trans man and/or non-binary person with a cervix is registered at a GP surgery as male, they may not have disclosed their sex assigned at birth. This means you may not know that they are eligible for cervical screening.

Disclosing that they are trans or non-binary may be very difficult for someone. Not only could it trigger distressing feelings within that person, they may fear potential repercussions – for example, transphobia or discrimination.

Tips for creating a safe environment for disclosure

Avoid making assumptions

We often make immediate assumptions about someone’s gender identity based on visual factors, including how they look physically or the clothes they wear.

Trans men and/or non-binary people with a cervix have been turned away from cervical screening because the reception staff or sample taker have assumed they do not need it based on external factors.

Equally, non-binary people who look more traditionally feminine have been assumed to be women. While this may mean they have easier access to an appointment, the experience erases who they are as an individual.

There is sometimes an assumption that trans men and/or non-binary people have had gender confirmation surgery. This surgery alters someone’s physical appearance or sex characteristics to match their gender identity. It often involves removing the cervix, which would mean they are not eligible for cervical screening. However, many trans men and/or non-binary people are not able or choose not to have surgery.

These assumptions take away someone’s personal choice to attend cervical screening and puts them at increased risk of cervical cancer. It may also force them into disclosing their sex assigned at birth in a public or unsafe space.

Offer alternative ways to disclose

It is wrong for anyone to feel pressured into discussing their gender identity, but it’s important they feel supported to do so if they want to. Some people may prefer to:

write it down
have a trusted person speak on their behalf – in this case, you may need written consent from the patient.

Be discreet and respectful

While some people will feel comfortable having conversations about their gender in a more public space, many people will not. If you are working on the reception desk, you may not have access to a private space. Instead, you can try other methods of respecting someone’s privacy:

You could offer or use the non-verbal methods of disclosure we suggest above.
Avoid openly naming the test that the patient is there for, which may unintentionally disclosure their sex assigned at birth to others in the room. For example, you could say ‘Have you been for this test before? Do you have any questions about it?’.

If you are a sample taker and want to check whether someone is there for cervical screening, invite them into a private space like the examination room. As always, it is important to explain what happens during cervical screening before the test. You could also ask:

We have you booked in for a cervical screening appointment. Is that right?
Have you been for cervical screening before?

Confidentiality

If a patient discloses their gender identity, you will need to have a conversation with the patient about recording this information. Some trans and/or non-binary patients may be anxious about having this on record, but you can offer some reassurance:

Explain that medical records are confidential. In line with the NHS confidentiality Code of Practice, information provided in confidence should not be used or disclosed in a form that might identify a patient without his or her consent. It may help to explicitly say that their gender identity will not be discussed informally with other members of staff or anyone else.
Explain that this information is relevant to their health. It may affect whether they are invited to partake in health interventions such as cervical screening, as well as any follow up appointments that may be needed. It may also be important for other healthcare professionals to know, so they can sensitively support the patient with any other health concerns.

Read the NHS Code of Practice on confidentiality >

Negative or inappropriate reactions

Although understanding and recognition of trans and/or non-binary people has improved in recent years, prejudice and discrimination against the community is still a reality. As well as overt transphobia, this can include microaggressions, such as commenting on someone’s name or making a joke about their physical appearance.

Tips for avoiding negative or inappropriate reactions

Train clinical and non-clinical staff

Some staff may not feel confident in supporting trans and/or non-binary people, which can lead to these patients feeling unsafe or unseen at their GP surgery or clinic. Healthcare is a basic human right, so it is vital that trans and/or non-binary people feel welcomed and understood by the professionals who offer that care.

LGBT Foundation run a Pride in Practice programme for anyone who wants to increase their knowledge and confidence of LGBT+ inclusion at home, at work and in the community. Find out more about Pride in Practice >

Be explicitly welcoming of trans and/or non-binary people

Make it easy for trans and/or non-binary to see that you recognise and welcome them. Your GP surgery or clinic could:

include LGBTQ or trans-specific posters in waiting and examination rooms
have a note addressed to trans and/or non-binary patients on the website.

Consider the reactions of other patients

Do you use digital screens that display patient names when their appointment room is ready? Sometimes a name may be traditionally masculine or feminine, or not match someone’s appearance, which could prompt negative reactions from others. Check which name the patient would prefer you to use – it may be that they are registered with a different name.

Do you have a separate room or area where patients arriving for cervical screening are invited to wait? If you do, this space is likely to be mostly used by cis women. While you can’t control how other people may react, you can check in with your trans and/or non-binary patients and be ready to step in if you witness transphobia or discrimination.

Misgendering and using incorrect language

Misgendering is referring to someone by the wrong gender. It is disrespectful to misgender someone and can be incredibly painful for that person. More broadly, incorrect language or terminology, such as using the wrong pronouns or deadnaming, can have the same impact.

A good way to avoid this is to ask questions about anything you are unsure of. This opens up the conversation for the patient and lets them know you want to understand their gender identity. Remember, everyone makes mistakes from time to time. If this happens, you can acknowledge them, correct yourself, learn from them, and move on.

You could say:

I use these pronouns [share your pronouns – for example, ‘she/her’]. What pronouns should I use for you?
I may need to write notes about you regarding this visit. What pronouns would you like me to use?
What gender should I note down for you / What is your gender?

If a patient you have seen before has transitioned or started transitioning, you could ask:

Remind me of your name?
Remind me what pronouns I should use for you?

It’s important to remember that, while the term trans may be a necessary qualifier in understanding why someone needs cervical screening, many people would usually describe themselves without it – for example, as a man. Listen to what the patient tells you and mirror their language.

Avoiding other assumptions

You should also avoid making assumptions about other aspects of someone's life based on their gender identity. For example, you may assume someone’s sexual orientation if you are explaining HPV risk and how it is passed on. Trans and/or non-binary people can be of any sexual orientation, just like everyone else. You can use the term ‘partner’ or ask ‘What sex are your sexual partners?’.

Dysphoria

Gender dysphoria describes a sense of unease or distress that a person may feel because of a mismatch between their sex assigned at birth and their gender identity.

As a gynaecological test, cervical screening involves parts of the body linked to sex assigned at birth, so it may trigger a harmful reaction. This could include damage to someone’s mental health and wellbeing, freezing, dissociation and panic.

Not everyone experiences dysphoria, but it is important to be mindful of it. It’s also okay to ask your patient whether they do, as it may be difficult for them to talk about.

Offering practical and emotional support for dysphoria

Agree on the language you will use

Like any appointment, it is important to explain cervical screening and check if there are any questions. Before you do this, it is best to agree on the language you will be using:

Ask ‘How would you like me to refer to this body part?’
Ask ‘Are there any words or language you’d like me to avoid?’
Avoid personalising body parts. For example, instead of ‘your cervix’ say ‘the cervix’.

Tell them they can bring someone they trust

Although coronavirus (COVID-19) means it may not be possible to bring someone into the appointment, having someone come with them to the GP surgery or clinic and wait outside may be comforting.

Give the option of seeing and touching the equipment

Some people may feel more comfortable after seeing or touching the speculum and brush, while others might prefer to see as little as possible. Having the option gives someone more control over their appointment and, by extension, their body.

Give the option of inserting the speculum themselves

This may help people feel more in control of the test and their own body. If a partner or trusted person has been allowed into the appointment, they may also be able to insert the speculum.

Barriers due to testosterone replacement therapy

Some trans men and/or non-binary people may be having testosterone replacement therapy (TRT). The male hormone is given as part of hormone therapy to help someone’s body better match their gender identity.

Vaginal atrophy

TRT can cause vaginal atrophy, which is the thinning, drying and inflammation of the vaginal walls and tissue. It is often caused by a lack of oestrogen in the vaginal tissues. It can make inserting the speculum during cervical screening much more uncomfortable or painful. There are ways to lessen this, including:

offering a smaller speculum size.
offering more lubrication.

Topical oestrogen

Topical oestrogen delivers oestrogen to an area that is lacking in this hormone, with methods including a vaginal cream or slow-dissolving vaginal tablets. Although topical oestrogen is an effective treatment, it is important to recognise that, as a female hormone, it may not be acceptable for a trans man and/or non-binary person.

If topical oestrogen would be helpful for your patient, you may want to explain that it will have very little effect on a trans man and/or non-binary person. The skin acts as a barrier with topical treatments, which means only a small amount of the hormone itself is absorbed into the body.

It is important that the patient is given the information to make the final decision about whether to have topical oestrogen.

Visual changes

TRT can cause the clitoris to grow. This is sometimes referred to as bottom growth.

While clitoral growth doesn’t affect cervical screening itself, the patient may be worried about your reaction to how their genitals look. As you would with any patient, avoid commenting on or reacting to their genitals, unless there is a health issue you need to address.

Incorrect sample processing

Samples taken during cervical screening need to be clearly labelled and communicated to the laboratory. If a sample is rejected and another cervical screening test is needed, this means a trans man and/or non-binary person has to relive a potentially distressing experience.

Other barriers

It’s important to remember that trans and/or non-binary people may also experience other barriers, such as fear of results, access to the test and past trauma. As you would with any patient, it is vital you recognise this and support them with each individual need.

Read our information for professionals about supporting survivors of sexual violence >

We also have general tips for supporting people before, during and after cervical screening. Read our tips >

Your impact

It is impossible to understate the importance of the sample taker, and the patient’s relationship with their sample taker, when it comes to a sensitive test like cervical screening.

By taking these steps and becoming a model for trans and/or non-binary healthcare within your GP surgery or clinic, you will be supporting someone to have an important health test, as well as making it more likely that they will come back again.

Further support

It may be appropriate for you to signpost trans men and/or non-binary people to expert organisations who can offer specific support. We have complied a list of trustworthy organisations you can use, although it is worth checking whether there are local organisations that can offer support.

Get the details of expert organisations >

Jo’s Cervical Cancer Trust can also provide support around cervical health, including symptoms, cervical screening, colposcopy and a cervical cancer diagnosis. You can signpost people to our free Helpline on 0808 802 8000, our Ask the Expert service or our website.

See our support services >

Cervical screening for trans men and/or non-binary people – Our cervical screening information aimed at trans men and/or non-binary people, including tips for making the appointment better. Read our information >
NHS population screening: information for trans and non-binary people (England) – Information for trans and/or non-binary people in England. It explains the adult NHS screening programmes that are available and who is invited for screening. Read this resource >
Screening information for transgender community (Scotland) – Information for trans and/or non-binary people in Scotland. It explains the adult NHS screening programmes that are available and who is invited for screening. Read this resource >
Screening information for transgender service users (Wales) – Information for trans and/or non-binary people in Wales. It explains the adult NHS screening programmes that are available and who is invited for screening. Read this resource >
Reducing cervical screening inequalities for trans people – A blog by Public Health England exploring inequalities in the current system using personal stories. Read the blog >

Thank you to all the experts who checked the accuracy of this information, and the volunteers who shared their personal experience to help us develop it. A special thanks to Harris, Laurie, Nat and Seb for allowing us to share their stories.

This information was developed in response to research done by Jo’s Cervical Cancer Trust in collaboration with Tavistock and Portman NHS Foundation Trust and 56 Dean Street.

References

Berner, AM et al (2020). A Survey of Attitudes to Cervical Cancer Screening in Trans Men and Non-binary People in the UK. Manuscript under review.
Connolly, D., Hughes, X. and Berner, AM. (2020). Barriers and facilitators to cervical cancer screening among transgender men and non-binary people with a cervix: A systematic narrative review. Preventative Medicine. 135.
Whitehead, B. (2017). Inequalities in Access to Healthcare for Transgender Patients. Links to Health and Social Care. Vol 2(1). pp.63-76.
Irwig, M. S. (2017). Testosterone therapy for transgender men. Diabetes and Endocrinology. 5(4). pp.301-311
Stonewall (2017). LGBT in Britain – Trans report. Web: www.stonewall.org.uk/lgbt-britain-trans-report. Accessed August 2020.

We write our information based on literature searches and expert review. For more information about the references we used, please contact [email protected]

August 2023 - Please be aware that this information for health professionals is currently undergoing regular review in line with our editorial policy. However the information remains valid.