A Literature Review of Cervical Cancer Screening in Transgender Men

Gynecologic health care for LGBTQIA+ people

Gender relations are a set of socially determined norms and rules that assign values, characteristics, and expectations to individuals based on their biological sex. These aspects also influence the clinician-patient relationship, since it has been for a long time based on cisheteronormativity. However, this attitude alienated the LGBTQIA+ community from health services. Global and specific gynecologic care needs to be offered to the LGBTQIA+ population, which has demands for sexual and reproductive health care. In this narrative review, we bring conceptual aspects, gender identity and expression, sexual history, screening for cancer and other care to the community.

Prevalence and Determinants of Cervicovaginal, Oral, and Anal Human Papillomavirus Infection in a Population of Transgender and Gender Diverse People Assigned Female at Birth

Purpose: The human papillomavirus (HPV) causes cervicovaginal, oral, and anogenital cancer, and cervical cancer screening options include HPV testing of a clinician-collected sample. Transgender and gender diverse (TGD) people assigned female at birth (AFAB) face many barriers to preventive care, including cancer screening. Self-sampling options may increase access and participation in HPV testing and cancer screening. This study estimated the prevalence of HPV in self-collected cervicovaginal, oral, and anal samples from Midwestern TGD individuals AFAB. Methods: We recruited TGD individuals AFAB for an observational study, mailing them materials to self-collect cervicovaginal, oral, and anal samples at home. We tested samples for high-risk (HR; 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59) and other HPV genotypes (6, 11, 66, 68, 73, 90) using a polymerase chain reaction mass array test. Prevalence ratios for HPV infection at each site as a function of participant characteristics were estimated in log-binomial models. Results: Out of 137 consenting participants, 102 completed sample collection. Among those with valid tests, 8.8% (HR = 6.6%; HPV 16/18 = 3.3%) were positive for oral HPV, 30.5% (HR = 26.8%; HPV 16/18 = 9.7%) for cervicovaginal HPV, and 39.6% (HR = 33.3%; HPV 16/18 = 8.3%) for anal HPV. A larger fraction of oral (71.4%) than anal infections (50.0%) were concordant with a cervicovaginal infection of the same type. Conclusions: We detected HR cervicovaginal, oral, and anal HPV in TGD people AFAB. It is essential that we reduce barriers to cancer screening for TGD populations, such as through the development of a clinically approved self-screening HPV test.

Transgender and non-binary peoples experiences of cervical cancer screening: A scoping review

AIM(S)

To synthesise the literature about transgender and non-binary people's experiences of cervical cancer screening and identify ways to improve screening.

BACKGROUND

Transgender people often face barriers to accessing health services including cervical screening, where transgender people have a lower uptake than cisgender women.

DESIGN

A scoping review was undertaken following the Arksey and O'Malley (2005) framework and the PRISMA-ScR checklist. Following database searching of Medline via PubMed, Web of Science, Scopus and CINHAL, 23 papers published between 2008 and 2003 were included. Papers were included if they shared trans and non-binary people's experiences of cervical screening and were written in English. There were no date or geographical data restrictions due to the paucity of research.

RESULTS

Transgender people experience barriers to cervical screening including gender dysphoria, a history of sexual trauma, and mistrust in health professionals or health services, which can result in having negative experiences of screening or avoiding screening. Health professionals can help to create a positive experience by informing themselves about best practices for trans+ health.

CONCLUSION

Changes are required to improve transgender people's experiences and uptake of cervical screening. Improving medical education about trans health and updating health systems would help to combat issues discussed.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Having an understanding of the reasons why accessing health services can be more difficult for transgender people will help health professionals to provide appropriate care for transgender patients. This paper details this in the context of cervical cancer screening and can be applied to other areas of healthcare.

REPORTING METHOD

We have adhered to relevant EQUATOR guidelines and used the PRISMA-ScR reporting method. No Patient or Public Contribution.

Primary and secondary prevention of cervical cancer among Italian AFAB transgender people

OBJECTIVE

Currently, available data on preventive measures for Human Papillomavirus (HPV) infection and cervical cancer in the transgender assigned female at birth (AFAB) community are extremely limited. Our aim was to analyze adherence to primary and secondary cervical cancer prevention screening programs among transgender AFAB people attending our gender clinic.

METHODS

Transgender AFAB people attending our center were recruited. Anamnestic data were collected for each person through completion of a medical history form and medical records. Variables recorded included previous HPV vaccination, adherence to regional screening programs (Pap smear or HPV DNA test), subject age, duration of current or prior gender-affirming hormone therapy (GAHT) and whether gender affirmation surgery (GAS) with hysterectomy had been performed. Open questions regarding reasons for not undergoing screening tests were also included.

RESULTS

In this cross-sectional study, 263 AFAB transgender people were included, with a mean age of 30.6 ± 10.5 years. GAS with hysterectomy had been performed on 37.6 % of these people. Of our participants, 71.7 % who were born after 1998 (the first cohort to receive HPV vaccination invitations in Italy) had been vaccinated for HPV. Seventy-four-point-nine percent of participants who were still eligible for cervical screening had never undergone Pap smear or HPV DNA testing, whereas those who had undergone at least one cervical screening had done so on average 4.2 ± 4.5 years ago.

CONCLUSION

HPV vaccination prevalence in the AFAB transgender population born after 1998 is in line with the Italian AFAB general population. However, adherence to cervical cancer screening programs in the transgender AFAB population appears to be lower in comparison to the cisgender population. Further efforts are required from the medical community to enhance AFAB transgender people's adherence to HPV vaccination and to cervical screening.

Cervicovaginal and Anal Self-Sampling for Human Papillomavirus Testing in a Transgender and Gender Diverse Population Assigned Female at Birth: Comfort, Difficulty, and Willingness to Use

Purpose: Transgender and gender diverse (TGD) people assigned female at birth (AFAB) face numerous barriers to preventive care, including for cervical cancer screening. At-home human papillomavirus (HPV) testing may expand access to cervical cancer screening for TGD people AFAB. This study assessed the perceptions of TGD individuals AFAB who self-collected cervicovaginal and anal samples. Methods: We recruited TGD individuals AFAB to collect cervicovaginal and anal specimens at home using self-sampling for HPV testing, and individuals reported their perceptions of self-sampling. Associations between demographic and health characteristics and each of comfort of use, ease of use, and willingness to use self-sampling were estimated using robust Poisson regression. Results: Of 137 consenting participants, 101 completed the sample collection and the surveys. The majority of participants reported that the cervicovaginal self-swab was not uncomfortable (68.3%) and not difficult to use (86.1%), and nearly all (96.0%) were willing to use the swab in the future. Fewer participants found the anal swab to not be uncomfortable (47.5%), but most participants still found the anal swab to not be difficult to use (70.2%) and were willing to use the swab in the future (89.1%). Participants were more willing to use either swab if they had not seen a medical professional in the past year. Conclusions: TGD individuals AFAB were willing to use and preferred self-sampling methods for cervicovaginal and anal HPV testing. Developing clinically approved self-sampling options for HPV testing could expand access to cancer screening for TGD populations.

Treatment patterns and outcomes for primary uterine leiomyosarcoma with synchronous isolated lung metastases: A National Cancer Database study of primary resection and metastasectomy

Background

One third of patients with uterine leiomyosarcomas (uLMS) present with distant metastases. Current guidelines do not include recommendations around surgery for metastatic uLMS. Patients with distant metastases commonly receive primary tumor resection for symptoms and so oncologic outcomes after surgery warrant exploration. We describe treatment patterns and outcomes for uLMS patients with synchronous isolated lung metastases (SILM).

Methods

This retrospective analysis of the National Cancer Database identified patients with uLMS and SILM. Patients with non-pulmonary metastases were excluded. We collected demographic, disease, and treatment characteristics and assessed clinicopathologic factors associated with the receipt of surgery on multivariate regression. Median, 1-year, and 5-year overall survival (OS) across treatment approaches were compared using Kaplan-Meier curves and log-rank tests. Multivariate Cox proportional hazard regressions identified independent predictors of survival.

Results

We identified 905 patients with uLMS and SILM between 2004 and 2017. 600 patients had primary tumor resection; 63 also had curative intent surgery with metastasectomy. Patients who did not receive chemotherapy were older (p<0.01) with a higher comorbidity index (p<0.05). Women with private health insurance were more likely to receive chemotherapy (p<0.01) and primary tumor resection (p<0.01). Patients who underwent curative intent surgery had 1-year OS of 71.2% and 5-year survival of 18% compared to 1-year survival of 35.6 % and 5-year survival of 5.16 % for patients who had no surgery. Black women had poorer survival on multivariate regression.

Conclusions

Primary tumor resection and curative intent surgery are associated with improved OS in uLMS with SILM and may be a reasonable treatment option in appropriately selected patients.

Sexual orientation and gender identity inequities in cervical cancer screening by race and ethnicity

BACKGROUND

In the United States, inequities in preventive health behaviors such as cervical cancer screening have been documented. Sexual orientation, gender identity, and race/ethnicity all individually contribute to such disparities. However, little work has investigated their joint impact on screening behavior.

METHODS

Using sampling weighted data from the 2016 and 2018 Behavioral Risk Factor Surveillance System, we assessed differences in two metrics via chi-square statistics: 1) lifetime uptake, and 2) up-to-date cervical cancer screening by sexual orientation and gender identity, within and across racial/ethnic classifications.

RESULTS

Within all races, individuals who identify as members of sexual and gender minority (SGM) communities reported higher rates of never being screened (except for Black transgender men) than straight or cisgender individuals (p < 0.0001). [*START* Across all races, the Asian/Pacific Islander transgender population (32.4%; weighted n (w.n.) = 1,313) had the lowest proportion of lifetime screening, followed by the Asian/Pacific Islander gay/lesbian (53.0%, w.n. = 21,771), Hispanic transgender (58.7%; w.n. = 24,780), Asian/Pacific Islander bisexual (61.8%, w.n. = 54,524), and Hispanic gay/lesbian (69.6%, w.n. = 125,781) populations. *END*] Straight or cisgender Non-Hispanic White (w.n. = 40,664,476) individuals had the highest proportion of lifetime screening (97.7% and 97.5%, respectively). However, among individuals who had been screened at least once in their lifetime, identifying as SGM was not associated with a decreased proportion of up-to-date screening within or between races.

CONCLUSIONS

Due to small sample sizes, especially among Asian/Pacific Islander and Hispanic populations, confidence intervals were wide. Heterogeneity in screening participation by SGM status within and across racial/ethnic groups were observed.

IMPACT

These screening disparities reveal the need to disaggregate data to account for intersecting identities and for studies with larger sample sizes to increase estimate reliability.

Cancer Screening for Transgender Individuals: Guidelines, Best Practices, and a Proposed Care Model

Few transgender-specific cancer screening recommendations exist. This review aims to cover current guidelines and practice patterns of cancer screening in transgender patients and, where evidence-based data are lacking, to draw from cisgender screening guidelines to suggest best practices for transgender patients based on anatomic inventory. Sufficient evidence does not exist to determine the long-term effects of gender-affirming hormone therapy on cancer risk. In the future, cancer screening and prevention should be focused on anatomic inventory and high-risk behaviors.

Understanding Sexual and Gender Minority Populations and Organ-Based Screening Recommendations for Human Papillomavirus-Related Cancers

OBJECTIVES

Sexual gender minority (SGM) populations are at risk for human papillomavirus (HPV)-related cancers of the anogenital tract and oropharynx and often face barriers to health care. The goals of this document are to clarify language to provide inclusive care for SGM populations and to provide recommendations for screening and prevention of HPV-related cancers in SGM populations.

MATERIALS AND METHODS

An expert committee convened by the American Society for Colposcopy and Cervical Pathology performed a narrative review of the literature through February 2023. A comprehensive MEDLINE database search was performed for relevant studies. The literature review was divided into categories by organ/topic and by SGM population. Given the variability in available data for several of the categories, recommendations were made based on national guidelines where appropriate or expert opinion where there were less data to support risk-based guidelines.

RESULTS

Definitions and terminology relevant to SGM populations are presented. The authors advocate the adoption of sexual orientation gender identity data collection and an organ-based screening approach, which is possible with knowledge of patient anatomy, sexual behaviors, and clinical history. This includes screening for cervical cancer per national recommendations, as well as screening for anal, vulvar, vaginal, penile, and oral cancers based on risk factors and shared clinical decision making. The authors recommend consideration of HPV vaccination in all SGM individuals up to age 45 years old who are at risk.

CONCLUSIONS

An organ-based screening approach is part of a global strategy to create an inclusive care environment and mitigate barriers to screening and prevention of HPV-mediated cancers in SGM populations.

Prevalence and determinants of cervicovaginal, oral, and anal HPV infection in a population of transgender and gender diverse people assigned female at birth

Introduction

HPV causes oral, cervicovaginal, and anogenital cancer, and cervical cancer screening options include HPV testing of a physician-collected sample. Transgender and gender diverse (TGD) people assigned female at birth (AFAB) face discrimination and stigma in many healthcare settings; are believed to be a lower risk for cervical cancer by many physicians; are less likely to be up to date on preventive health care services such as pelvic health exams; and are more likely to have inadequate results from screening tests. Self-sampling options may increase access and participation in HPV testing and cancer screening.

Methods

We recruited 137 TGD individuals AFAB for an observational study, mailing them a kit to self-collect cervicovaginal, oral, and anal samples at home. We tested samples for HPV genotypes 6, 11, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, 68, 73 and 90 using a PCR mass array test.

Results

102 participants completed the study. Among those with valid tests, 8.8% were positive for oral HPV, 30.5% were positive for cervicovaginal HPV, and 39.6% were positive for anal HPV. A large fraction of anal (50.0%) and oral (71.4%) infections were concordant with a cervicovaginal infection of the same type.

Conclusions

HPV infection in TGD people AFAB may be just as high, if not higher, than in cisgender women. It is essential that we reduce barriers to cancer screening for TGD populations, such as through the development of a clinically approved self-screening HPV test.

Cervicovaginal and anal self-sampling for HPV testing in a transgender and gender diverse population assigned female at birth: comfort, difficulty, and willingness to use

Background

Transgender and gender diverse (TGD) people assigned female at birth (AFAB) face numerous barriers to preventive care, including for HPV and cervical cancer screening. Self-sampling options may expand access to HPV testing for TGD people AFAB.

Methods

We recruited TGD individuals AFAB to collect cervicovaginal and anal specimens at-home using self-sampling for HPV testing, and individuals reported their perceptions of self-sampling. Associations between demographic and health characteristics and each of comfort of use, ease of use, and willingness to use self-sampling were estimated using robust Poisson regression.

Results

The majority of the 101 participants who completed the study reported that the cervicovaginal self-swab was not uncomfortable (68.3%) and not difficult to use (86.1%), and nearly all (96.0%) were willing to use the swab in the future. Fewer participants found the anal swab to not be uncomfortable (47.5%), but most participants still found the anal swab to not be difficult to use (70.2%) and were willing to use the swab in the future (89.1%). Participants were more willing to use either swab if they had not seen a medical professional in the past year. About 70% of participants who reported negative experiences with either self-swab were still willing to use that swab in the future.

Conclusions

TGD AFAB individuals were willing to use and preferred self-sampling methods for cervicovaginal and anal HPV testing. Developing clinically approved self-sampling options for cancer screening could expand access to HPV screening for TGD AFAB populations.

Cancer screening and management in the transgender population: Review of literature and special considerations for gender affirmation surgery

BACKGROUND

Literature focused on cancer screening and management is lacking in the transgender population.

AIM

To action to increase contributions to the scientific literature that drives the creation of cancer screening and management protocols for transgender and gender nonconforming (TGNC) patients.

METHODS

We performed a systematic search of PubMed on January 5th, 2022, with the following terms: "TGNC", OR "transgender", OR "gender non-conforming", OR "gender nonbinary" AND "cancer screening", AND "breast cancer", AND "cervical cancer", AND "uterine cancer", AND "ovarian cancer", AND "prostate cancer", AND "testicular cancer", AND "surveillance", AND "follow-up", AND "management". 70 unique publications were used. The findings are discussed under "Screening" and "Management" categories.

RESULTS

Screening: Current cancer screening recommendations default to cis-gender protocols. However, long-term gender-affirming hormone therapy and loss to follow-up from the gender-specific specialties contribute to a higher risk for cancer development and possible delayed detection. The only known screening guidelines made specifically for this population are from the American College of Radiology for breast cancer. Management: Prior to undergoing Gender Affirmation Surgery (GAS), discussion should address cancer screening and management in the organs remaining in situ. Cancer treatment in this population requires consideration for chemotherapy, radiation, surgery and/or reconstruction. Modification of hormone therapy is decided on a case-by-case basis. The use of prophylactic vs aesthetic techniques in surgery is still debated.

CONCLUSION

When assessing transgender individuals for GAS, a discussion on the future oncologic risk of the sex-specific organs remaining in situ is essential. Cancer management in this population requires a multidisciplinary approach while the care should be highly individualized with considerations to social, medical, surgical and gender affirming surgery related specifications. Special considerations have to be made during planning for GAS as surgery will alter the anatomy and may render the organ difficult to sample for screening purposes. A discussion with the patient regarding the oncologic risk of remaining organs is imperative prior to GAS. Other special considerations to screening such as the conscious or unconscious will to unassociated with their remaining organs is also a key point to address. We currently lack high quality studies pertinent to the cancer topic in the gender affirmation literature. Further research is required to ensure more comprehensive and individualized care for this population.

Social determinants of sex disparities in cancer in Southeast Asia

Sex disparities in cancer exist along the cancer spectrum, ranging from genomic predisposition and behavioral risk factors to access to screening, diagnostics, treatment, and survivorship care. A growing body of research is studying the biological underpinnings of these differences, from cancer risk to tumor biology to treatment response. It is well known, however, that the social determinants of health play a large role across the cancer disease continuum, which encompasses risk, prevention, diagnosis, treatment, survivorship, rehabilitation, and palliative care. Less literature focuses on the gendered disparities that are epidemiologic in nature, especially in Southeast Asia (SEA), a diverse region that is home to nearly 670 million people, where most are lower middle income countries, and where socioeconomic and cultural factors increase cancer risk for women. In this review, we highlight the social drivers of gendered disparities, namely the geographic, environmental, sociocultural, economic, and political forces that contribute to the increased mortality and poorer health outcomes in the region.

The impact of rurality on vulvodynia diagnosis and management: Primary care provider and patient perspectives

Objective

The objective of this study was to better understand how rurality impacts the knowledge, diagnosis and management of vulvodynia by primary care providers (PCPs) practising in the geographically disparate province of Newfoundland and Labrador, Canada.

Design

This was a qualitative case study using questionnaires and semi-structured interviews with PCPs, compared with semi-structured focus groups and interviews with vulvodynia patients conducted in a previous study phase.

Results

Ten family physicians and 6 nurse practitioners participated. Over half had baseline knowledge that vulvodynia has a relatively high prevalence, but most underestimated the likelihood they would see a patient with vulvodynia in their practice. Three barriers to discussing and managing vulvodynia emerged: (1) discomfort initiating sexual/vulvar health conversations; (2) concerns about protecting patient privacy and confidentiality; and (3) time constraints and building therapeutic relationships. These issues were largely corroborated by previous findings with vulvodynia patients. Rural-informed solutions might include: (1) supporting increased education in vulvodynia and sexual health more broadly, including funding to attend continuing professional education and developing more clinical tools; (2) following practice guidelines regarding standardised initiation of sexual health conversations; (3) incentivising retention of rural providers and extending appointment times by reconsidering fee-for-service structures; and (4) researching a tailored vulvodynia toolkit and the potential advantage of mobile health units.

Conclusion

Rurality exacerbates common concerns in the identification and management of vulvodynia. Acting on recommended solutions may address the impact of rurality on the provision of timely care for those experiencing vulvodynia and other sexual health concerns.

Canadian Guideline on the Management of a Positive Human Papillomavirus Test and Guidance for Specific Populations

The purpose of this paper is to provide evidence-based guidance on the management of a positive human papilloma virus (HPV) test and to provide guidance around screening and HPV testing for specific patient populations. The guideline was developed by a working group in collaboration with the Gynecologic Oncology Society of Canada (GOC), Society of Colposcopists of Canada (SCC), and the Canadian Partnership Against Cancer. The literature informing these guidelines was obtained through a systematic review of relevant literature by a multi-step search process led by an information specialist. The literature was reviewed up to July 2021 with manual searches of relevant national guidelines and more recent publications. The quality of the evidence and strength of recommendations were developed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. The intended users of this guideline include primary care providers, gynecologists, colposcopists, screening programs, and healthcare facilities. The implementation of the recommendations will ensure an optimum implementation of HPV testing with a focus on the management of positive results. Recommendations for appropriate care for underserved and marginalized groups are made.

Disparities in Prostate Cancer Screening for Transgender Women: An Analysis of the MarketScan Database

OBJECTIVE

To describe the prevalence of PSA screening amongst transgender women. A transgender individual is someone whose gender identity differs from their birth sex or the societal norms of that assigned sex. There are no formal guidelines regarding PSA screening in transgender women, even though they retain prostatic tissue throughout the gender-affirming process, and there is a lack of existing data to adequately inform clinical practice.

METHODS

We identified a cohort of transgender women in the IBM MarketScan dataset using ICD codes. The patient...s eligibility for inclusion was determined on an annual basis for the years 2013-2019. For each year, we required continuous enrollment, 3 months of post-transgender diagnosis follow-up, and aged 40-80 without a prior diagnosis of prostate malignancy. This cohort was compared to cisgender men with similar eligibility criteria. The proportions of individuals undergoing PSA screening were compared using log-binomial regression.

RESULTS

A group of 2957 transgender women met the inclusion criteria. We saw significantly lower PSA screening rates among transgender individuals for ages 40-54 and 55-69, but higher rates within the age group 70-80 (P.ß<.ß.001 for all).

CONCLUSION

This is the first study evaluating PSA screening rates for insured transgender women. While the rates for screening in transgender women over the age of 70 are higher, the overall rate of screening for all other age groups lags below the general population in this dataset. Further investigation is necessary to provide equitable care for the transgender community.

Provision of cervical screening for transmasculine patients: a review of clinical and programmatic guidelines

BACKGROUND

Most cervical cancer can be prevented through routine screening. Disparities in uptake of routine screening therefore translate into disparities in cervical cancer incidence and outcomes. Transmasculine people including transgender men experience multiple barriers to cervical screening and their uptake of screening is low compared with cisgender women. Comprehensive evidence-based guidelines are needed to improve cervical screening for this group.

METHODS

We searched for and synthesised clinical and programmatic guidelines for the provision of cervical screening for transmasculine patients.

FINDINGS

The guidelines offer recommendations addressing: (1) reception, check-in and clinic facilities; (2) patient data and invitation to screening; (3) improving inclusion in screening programmes; and (4) sexual history taking, language and identity. Guidelines offer strategies for alleviating physical and psychological discomfort during cervical screening and recommendations on what to do if the screening procedure cannot be completed. Most of the guidelines were from and for high-income countries.

DISCUSSION

The evidence base is limited, but existing guidelines provide recommendations to ensure life-saving screening services are available to all who need them. We were only able to identify one set of guidelines for a middle-income country, and none for low-income countries. We encourage the involvement of transmasculine people in the development of future guidelines.

Improving menstrual equity in the USA: perspectives from trans and non-binary people assigned female at birth and health care providers

Menstruation research has largely focused on addressing menstrual management barriers facing cisgender women and girls in low and middle-income countries. Scant literature has assessed the menstrual management needs of trans and non-binary people assigned female at birth. To better understand these frequently invisibilised menstruation-related needs, we conducted a multi-method qualitative study in New York City which included: 17 in-depth interviews across trans and non-binary people (n = 10) and health care providers who serve them (n = 7); and seven anonymous post-interview participatory writing responses with trans and non-binary participants to further elucidate their lived experiences with menstrual management. Lack of health care provider transgender competency, public toilet design (i.e. gaps in cubicle doors and lack of in-cubicle menstrual product disposal bins), and the social dynamics of public toilets (i.e. work and school) were identified as significant barriers to managing menstruation safely and accessibly for trans and non-binary people. These findings have important implications for healthcare policy, public toilet legislation and advancing menstrual equity in the USA.

Addressing Misinformation About the Canadian Breast Screening Guidelines

Screening mammography has been shown to reduce breast cancer mortality by 41% in screened women ages 40-69 years. There is misinformation about breast screening and the Canadian breast screening guidelines. This can decrease confidence in screening mammography and can lead to suboptimal recommendations. We review some of this misinformation to help radiologists and referring physicians navigate the varied international and provincial guidelines. We address the ages to start and stop breast screening. We explore how these recommendations may vary for specific populations such as patients who are at increased risk, transgender patients and minorities. We identify who would benefit from supplemental screening and review the available supplemental screening modalities including ultrasound, MRI, contrast-enhanced mammography and others. We describe emerging technologies including the potential use of artificial intelligence for breast screening. We provide background on why screening policies vary across the country between provinces and territories. This review is intended to help radiologists and referring physicians understand and navigate the varied international and provincial recommendations and guidelines and make the best recommendations for their patients.

"Doing it on my own terms": Transgender and nonbinary adults' experiences with HPV self-swabbing home testing kits

The human papillomavirus (HPV) carries a significant health risk for people with a cervix. Among transgender and nonbinary people, however, testing and treatment for HPV can pose difficulties, and even be traumatic at times. This current study is part of a larger mixed methods study conducted in Michigan in 2020, and it explores the experiences of transmasculine and nonbinary people with at-home self-swabbing HPV test kits and knowledge of HPV transmission/screenings. Phenomenological methods were used by conducting virtual qualitative interviews with ten transmasculine and nonbinary individuals with cervixes, ages 23-59. Interviews were independently coded by members of the research team and a tabletop theming method was used. Four themes were generated from the data: 1) Multilevel barriers; 2) "Get it done, so I know that I am safe"; 3) Contrasting preferences for care; and 4) Community calls for change. The discussion focuses on the implications of these findings for improving sexual health care for the transgender and nonbinary community, along with directions for further research.

Interdisciplinary, Inclusive, and Innovative: Promoting a Paradigmatic Shift in Cancer Research Among Transgender and Gender Diverse Adolescents and Young Adults

Transgender and gender diverse (TGD) adolescents and young adults (AYA) face heightened risks of cancer due to cissexism and transphobia in healthcare, low cancer screening rates, limited knowledge and awareness of cancer risk and screenings, poor healthcare experiences, and exposure to sexually transmitted infections (STIs). Despite this, TGD AYA cancer risk is relatively unexamined in oncology research. To intervene early and mitigate risk, we require holistic understandings of cancer risk among TGD AYA. This research brief engages with an interdisciplinary knowledge base to identify gaps and limitations warranting critical attention by TGD AYA and cancer scholars. The current literature on TGD AYA risks for cancer are explored with specific attention to the social environment and its impact on cancer risk. The brief ends with a call to action for a paradigmatic shift to promote inclusive, innovative, and interdisciplinary cancer research with TGD AYA.

Comparison of Cervical Cancer Screen Results on Female-to-Male Transgender Patients With Female Patients

OBJECTIVES

There are limited data on cervical screen results from female-to-male (FTM) transgender patients. Herein, we compiled demographic information and cervical screen testing on FTM transgender patients and compared with age-appropriate controls.

METHODS

A search of our previous and current databases was performed for Papanicolaou (Pap) tests from patients taking testosterone and/or with a diagnosis of gender dysphoria, transsexualism, or transvestism. Patient data were reviewed. Relative risks of abnormal Pap smear and human papillomavirus (HPV) infection were calculated against age-matched controls.

RESULTS

Eighty-nine Pap tests from FTM transgender individuals were identified, with a mean age of 31.3 years (range, 21-60 years). The Pap test diagnoses were distributed as follows: negative for intraepithelial lesion (n = 84, 94.4%), atypical squamous cells of undetermined significance (n = 0), low-grade intraepithelial lesion (n = 4, 4.5%), and high-grade squamous intraepithelial lesion (n = 1, 1.1%). Fifty (56.2%) patients had concurrent high-risk HPV testing with four (8%) positive results. Relative risk was 0.625 (95% confidence interval [CI], 0.25-1.59; P = .32) for an abnormal Pap test and 0.55 (95% CI, 0.19-1.52; P = .24) for HPV compared with 267 age-matched controls. Of note, 13.5% of patients older than 21 years had documentation of never having a prior Pap test in our medical record.

CONCLUSIONS

In our study, FTM transgender individuals were not at a higher or lower risk of HPV infection or abnormal Pap test result compared with women. However, larger studies are needed to support our findings.

LGBTQ2S+ childbearing individuals and perinatal mental health: A systematic review

BACKGROUND

The perinatal period may uniquely impact the mental health and wellbeing of lesbian, gay, bisexual, transgender, queer, and Two-Spirit (LGBTQ2S+) childbearing individuals.

OBJECTIVES

To characterise and synthesise the experiences of LGBTQ2S+ childbearing individuals regarding perinatal mental health, including symptomatology, access to care and care-seeking.

SEARCH STRATEGY

We conducted and reported a systematic review following PRISMA guidelines of eight databases (EMBASE, MEDLINE-OVID, CINAHL, Scopus, Web of Science: Core Collection, Sociological Abstracts, Social Work Abstract, and PsycINFO) from inception to 1 March 2021.

SELECTION CRITERIA

Original, peer-reviewed research related to LGBTQ2S+ mental health was eligible for inclusion if the study was specific to the perinatal period (defined as pregnancy planning, conception, pregnancy, childbirth, and first year postpartum; includes miscarriages, fertility treatments and surrogacy).

DATA COLLECTION AND ANALYSIS

Findings were synthesised qualitatively via meta-aggregation using the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI SUMARI), and the ConQual approach.

MAIN RESULTS

Our systematic search included 26 eligible studies encompassing 1199 LGBTQ2S+ childbearing participants. Using the JBI SUMARI approach, we reported 65 results, which we synthesised as six key findings. The studies described unique considerations for LGBTQ2S+ individuals' perinatal mental health, including heteronormativity, cisnormativity, isolation, exclusion from traditional pregnancy care, stigma, and distressing situations from the gendered nature of pregnancy. Many participants described a lack of knowledge from healthcare providers related to care for LGBTQ2S+ individuals. In addition, LGBTQ2S+ individuals described barriers to accessing mental healthcare and gaps in health systems. Strategies to improve care include provider education, avoidance of gendered language, documentation of correct pronouns, trauma-informed practices, cultural humility training and tailored care for LGBTQ2S+ people.

CONCLUSIONS

Pregnancy, postpartum, and the perinatal period uniquely impacts the mental health and wellbeing of LGBTQ2S+individuals, largely due to systems-level inequities and exclusion from perinatal care. Healthcare providers should implement the identified strategies to improve perinatal care and address inequities.

Transmasculine Persons' Experiences of Encounters with Health Care Professionals Within Reproductive, Perinatal, and Sexual Health in Sweden: A Qualitative Interview Study

Purpose: Transmasculine persons may experience stigma, which increases the risk of psychological distress. They may need reproductive, perinatal, and sexual health care; however, qualitative studies addressing transgender individuals' experiences are scarce. This study aimed at interpreting and describing the experiences of transmasculine persons in encounters with health care professionals (HCPs) within reproductive, perinatal, and sexual health care.

Methods: Nine qualitative semi-structured online interviews were conducted via email with transmasculine persons, and data were analyzed by using Braun and Clarke's thematic analysis.

Results: Two themes were identified. The first theme is normalization and confirmation of the gender identity. This theme comprises the knowledge and experience that these transmasculine persons are facing. The verbal approach from the HCPs was important as well as could be addressed with a non-binary approach. The second theme is Respect in an especially exposed situation. This theme shows the great importance of being involved in the care and at the same time being met with openness and empathy. There must be good prospects of being able to preserve dignity.

Conclusion: Transmasculine persons are in an exposed position in reproductive, perinatal, and sexual health care. The encounters in health care could be negatively affected if HCPs show inadequate knowledge or express gender stereotypical attitudes. A good encounter is characterized by respect, preserved integrity, involvement in the care, and an open attitude toward gender variations.

Masculinity performed by transgender men: qualitative evidence and metasynthesis

Abstract Masculinity is a construct associated with cisgender men; however, transgender men also perform masculinities. This study aimed to synthesize, analyze, and reinterpret the findings of primary qualitative studies about transgender men’s experience of masculinity. The research question developed through the SPIDER strategy was: What is the qualitative evidence of masculinity performed by transgender men? Eighteen studies involving over 200 transgender men between the ages of 19 and 65 were selected. Three descriptive themes emerged: “Bodily performance of masculinity,” “Social performances of masculinity,” and “Sexualities.” Analytical themes were generated: “The appearance of masculinity” and “Far beyond appearance”. The results point to complementary experiences of masculinity: concerning physical appearance and body modifications; and the practices contesting the hegemonic masculinity standard. The experience of masculinities is outlined by body changes, culminating in the passability and social recognition of the transgender man.

Human papillomavirus-Inequalities in disease prevention and the impact on racial, ethnic, sexual, and gender minorities

HPV, a sexually transmitted viral infection, is the etiological agent of significant dermatologic disease including benign anogenital warts and invasive cancers. Sexual and gender minority individuals are particularly vulnerable to HPV-associated disease due to reduced vaccination rates in these cohorts, low awareness of HPV, lack of provider recommendation, and inadequate consensus guidelines on screening and prevention in these individuals. A targeted approach is needed with regards to vaccination in all children -especially those from racial, ethnic, sexual, and gender minorities; provider recommendation, especially from pediatric dermatologists, is crucial. Effort must also be made to use transgender and non-binary affirming language as dividing vaccination programs by anatomic sex and sexuality reinforces problematic notions of gender identity and sexuality, isolating the most vulnerable.

Key Informants Discuss Cancer Care Research for Trans and Gender Diverse People

The aim was to explore issues in relation to accessing cancer care for the Australian trans and gender diverse community through key informant interviews to inform a larger study on the topic. Semi-structured interviews were conducted with key informants who either had clinical and/or research experience with trans and gender diverse populations or were members of the community who act as advocates (total n = 14). Participants had diverse genders, including three transwomen, one transman, three non-binary people, six cis woman and one cis man. Thematic analysis was used to analyse the transcripts. Four themes were identified in the data: 'More Important Issues' than Cancer Concern, Experiences of Cancer Care, Barriers to Cancer Care and (Potential) Facilitating Factors to Access Cancer Care. The findings show the inconsistencies in awareness of cancer in the trans and gender diverse population, both within the community itself and in healthcare. There are issues concerning underutilization of screening services, healthcare workers lacking knowledge and an invisibility within organizations and systems. Education is needed in cancer care, as are partnerships with community organizations, inclusive policies, improved data collection on gender, targeted health promotion and research.

Bridging Barriers to Cervical Cancer Screening in Transgender Men: A Scoping Review

Estimates of high-risk human papillomavirus (HPV) infection and susceptibility to HPV-related cancer in transgender men (TM) are comparable to prevalence rates found in cisgender women. Regular and thorough screening for cervical cancer is equally as crucial for TM as for cisgender women; however, despite continued risk for cervical cancer in TM and associated recommendations for screening, studies indicate disparities in rates of cervical cancer screening (CCS) in TM compared to cisgender women. The current scoping review explores TM’s knowledge and experiences of CCS and barriers to screening uptake in this population. A range of barriers were identified including the need for health-care services to provide care for TM within the context of a nonbinary approach to gender identity and health. Findings synthesized from relevant research studies (n = 15; published 2008–2019) are presented, and recommendations are drawn from these findings to inform primary health-care providers’ clinical practice and care of TM.

Clinician's Experience and Self-Perceived Knowledge and Attitudes toward LGBTQ + Health Topics

Phenomenon: Research on clinicians' knowledge and attitudes toward lesbian, gay, bisexual, transgender, queer/questioning, and other sexual and gender minorities (LGBTQ+) health topics has relied mostly on small early-career samples. The influence of clinical experience on knowledge and attitudes has not been examined. The study purpose was to examine physicians' and advanced practice providers' (a) self-perceived knowledge and attitudes about LGBTQ + health topics, (b) the relationship between clinical experience and self-perceived knowledge and attitudes, and (c) preferences for LGBTQ + medical education.Approach: An online anonymous survey was emailed to 3667 physicians and advanced practice providers at a large southeastern multisite healthcare institution. Logistic regression determined associations between clinical experience, knowledge, and attitudes.Findings: There were 880 (24.0%) respondents. Most were physicians (70%). Thirty-eight percent had more than 15 years of experience. Fifty-four percent preferred online education. Few reported sophisticated knowledge of six LGBTQ + health topics (6%-10%). The majority felt that these were either important or very important for all physicians. After accounting for demographics, experience was not associated with knowledge or attitudes.Insights: Knowledge gaps yet positive attitudes suggest that additional training on LGBTQ + patients is warranted and likely to be well received. The lack of influence of experience on knowledge and attitudes may suggest that training is applicable to clinicians of all experience levels. Future research should determine if knowledge and attitudes toward LGBTQ + health topics influence culturally competent healthcare practices.

Human Papillomavirus Vaccination Among Transgender and Gender Diverse People in the United States: An Integrative Review

Objective

This integrative review explores the barriers to and facilitators for human papillomavirus (HPV) vaccination among adult transgender and gender diverse (TGD) people in the United States.

Data Source

A systematic search of electronic databases included PubMed/MEDLINE, CINAHL, and EMBASE from 1985 to 2020.

Inclusion and Exclusion Criteria

Inclusion criteria included studies from the United States that described HPV vaccination barriers or facilitators and included adult TGD participants, both quantitative and qualitative studies. Exclusion criteria were studies that reported only HPV vaccine prevalence, non-English/non-U.S. studies, and studies limited to pediatric populations.

Data Extraction

Two investigators used Covidence software to screen studies and manage data extraction. Quality of the quantitative studies was appraised using a checklist proposed by the Joanna Briggs Institute (JBI); qualitative studies were appraised using quality criteria informed by the literature.

Data Synthesis

The Social Ecological Model guided the review to organize barriers to and facilitators for HPV vaccination at the patient-, provider-, and system-levels.

Results

Database searches and hand-searching yielded 843 citations. After screening, eight articles were retained in the review. Seven were cross-sectional studies and one was a qualitative focus-group. All retained quantitative studies met six of the eight JBI quality checklist items.

Conclusion

The low proportion of TGD participants in the retained studies highlights a gap in knowledge about HPV vaccination among this population. Future studies of HPV vaccination should recruit TGD people to better represent their perspectives.

Preconception, Pregnancy, Birthing, and Lactation Needs of Transgender Men

Planned and unplanned pregnancies are occurring among transgender men. Although the literature highlights the fact that many transgender men retain their reproductive pelvic organs and desire pregnancy, there is a dearth of information on best practices and standards of care guiding perinatal care for this population. A literature review was conducted to explore the reproductive health needs of transgender men related to reproductive desires, contraception, family planning, fertility preservation, pregnancy, birth, and lactation. Findings show that pregnant and birthing transgender men are reporting feelings of invisibility, isolation, and loneliness in highly gendered perinatal care environments. A lack of gender-affirming perinatal environments and experienced providers is contributing to the avoidance of care by transgender men and further discrimination in an already marginalized population. More research attention is needed to understand the reproductive health needs of pregnant and birthing transgender men and to optimize the care they receive.

Cervical cancer screening in the United States: Challenges and potential solutions for underscreened groups

Cervical cancer screening rates in the United States are generally high, yet certain groups demonstrate disparities in screening and surveillance. Individuals at greatest risk for cervical cancer are often from marginalized or underserved groups who do not participate in regular screening for a variety of reasons. Using the Population-based Research to Optimize the Screening Process (PROSPR) Trans-Organ Conceptual Model, including concepts of individual-, provider-, facility-, system-, or policy-level factors, we provide a commentary to highlight reasons for low screening participation among subgroups in the U.S. These include racial and ethnic minorities, rural residents, sexual and gender minorities, those with limited English proficiency, those with particular religious beliefs, and various health conditions. We describe barriers and offer potential solutions for each group. In addition, we discuss cross-cutting barriers to screening including difficulty interacting with the healthcare system (limited knowledge and health literacy, lack of provider recommendation/contact), financial (cost, lack of insurance), and logistical barriers (e.g., lack of usual source of care, competing demands, scheduling issues). Solutions to address these barriers are needed to improve screening rates across all underscreened groups. Changes at state and national policy levels are needed to address health insurance coverage. Mobile screening, ensuring that interpreters are available for all visits, and targeted in reach at non-gynecological visits can further overcome barriers. Employing community outreach workers can increase community demand for screening, and patient navigators can improve adherence to both screening and follow-up diagnostic evaluation. HPV self-sampling can address multiple barriers to cervical cancer screening.

"When the pain is so acute or if I think that I'm going to die": Health care seeking behaviors and experiences of transgender and gender diverse people in an urban area

Introduction

Approximately 1.4 million transgender and gender diverse (TGD) adults in the United States have unique health and health care needs, including anatomy-driven cancer screening. This study explored the general healthcare experiences of TGD people in the Washington, DC area, and cancer screening experiences in particular.

Methods

Twenty-one TGD people were recruited through word of mouth and Lesbian Gay Bisexual Transgender Queer (LGBTQ)-specific community events. Participant interviews were conducted and recorded via WebEx (n = 20; one interview failed to record). Interviews were transcribed using Rev.com. Two coders conducted line-by-line coding for emergent themes in NVivo 12, developed a codebook by consensus, and refined the codebook throughout the coding process. Member checking was conducted to ensure credibility of findings.

Results

Three major themes served as parent nodes: health-care seeking behaviors, quality care, and TGD-specific health care experiences. Within these parent nodes there were 14 child nodes and 4 grand-child nodes. Subthemes for health care seeking behaviors included coverage and costs of care, convenience, trust/mistrust of provider, and provider recommendations for screening. Subthemes for quality of care included professionalism, clinical competence in transgender care, care coordination, provider communication, and patient self-advocacy. Overall, transgender men were less satisfied with care than transgender women.

Conclusions

Results suggest a need for improved provider communication skills, including clear explanations of procedures and recommendations for appropriate screenings to TGD patients. Results also suggest a need for improved clinical knowledge and cultural competency. Respondents also wanted better care coordination and insurance navigation. Overall, these findings can inform health care improvements for TGD people.

Cultural competence in fertility care for lesbian, gay, bisexual, transgender, and queer people: a systematic review of patient and provider perspectives

OBJECTIVE

To characterize the patient and provider perspectives on cultural competence in lesbian, gay, bisexual, transgender, and queer (LGBTQ+) fertility care.

DESIGN

Systematic review.

SETTING

Not applicable.

PATIENT(S)

LGBTQ+ patients and their partners treated for fertility-related care; fertility providers who treat LGBTQ+ patients.

INTERVENTION(S)

We conducted a systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines of six databases: Medline-OVID, EMBASE, CINAHL, Cochrane Library, ClinicalTrials.Gov, and PsycInfo. Citations of full-text articles were hand-searched using the Scopus database. Eligible studies were assessed using the Risk of Bias Instrument for Cross-Sectional Surveys of Attitudes and Practices, as well as the Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research. All screening, extraction, and appraisal were completed in duplicate with two independent reviewers.

MAIN OUTCOME MEASURE(S)

Patient-reported or provider-reported views on LGBTQ+ cultural competence in fertility care, including barriers and facilitators to inclusive care.

RESULT(S)

Of the 1,747 original database citations, we included 25 studies that met the inclusion criteria. Of the 21 studies that evaluated patient perspectives, 13 studies targeted same-sex cisgender couples while the remainder targeted transgender and gender-nonconforming participants (n = 6) or any individual who identified as a sexual or gender minority (n = 2). Key barriers for LGBTQ+ participants included gender dysphoria, heteronormativity, stigmatization, and psychological distress. The lack of tailored information for LGBTQ+ populations was repeatedly highlighted as a concern. Promising solutions included tailored information, psychosocial interventions, gender-neutral language, and inclusive intake processes.

CONCLUSION(S)

LGBTQ+ individuals face unique barriers in fertility care, as described by both patients and providers. This review describes a number of implementable solutions for equitable care, which should be given priority for both research and hospital interventions.

Cancer screening in the transgender population: a review of current guidelines, best practices, and a proposed care model

Over the last 50 years cancer mortality has decreased, the biggest contributor to this decrease has been the widespread adoption of cancer screening protocols. These guidelines are based on large population studies, which often do not capture the non-gender conforming portion of the population. The aim of this review is to cover current guidelines and practice patterns of cancer screening in transgender patients, and, where evidence-based data is lacking, to draw from cis-gender screening guidelines to suggest best-practice screening approaches for transgender patients. We performed a systematic search of PubMed, Google Scholar and Medline, using all iterations of the follow search terms: transgender, gender non-conforming, gender non-binary, cancer screening, breast cancer, ovarian cancer, uterine cancer, cervical cancer, prostate cancer, colorectal cancer, anal cancer, and all acceptable abbreviations. Given the limited amount of existing literature inclusion was broad. After eliminating duplicates and abstract, all queries yielded 85 unique publications. There are currently very few transgender specific cancer screening recommendations. All the guidelines discussed in this manuscript were designed for cis-gender patients and applied to the transgender community based on small case series. Currently, there is not sufficient to evidence to determine the long-term effects of gender-affirming hormone therapy on an individual’s cancer risk. Established guidelines for cisgender individuals and can reasonably followed for transgender patients based on what organs remain in situ. In the future comprehensive cancer screening and prevention initiatives centered on relevant anatomy and high-risk behaviors specific for transgender men and women are needed.

Considerations in genetic counseling of transgender patients: Cultural competencies and altered disease risk profiles

Transgender people are a growing population with specific healthcare needs, barriers to care, and disease risk factors. Cultural competencies for working with transgender people in healthcare settings are essential to reduce barriers to care and combat the associated health disparities. Genetic counselors support their patients to understand and manage medically and personally complex life events and decisions. A genetic counselor caring for a transgender patient or a patient with a transgender relative will therefore require specific cultural competencies and medical knowledge that may not have been covered in their training. Transgender health is also a relatively young field in which new insights may quickly become fundamental. The present paper therefore provides an overview of current best practices for culturally sensitive working with transgender patients, and an introduction to the additional considerations for assessment of disease risk in transgender people. Guidance on how to ensure communication with patients and other stakeholders is inclusive and affirming of transgender identities, is offered. Medical interventions used for gender transitions are described, and their (potential) effects on cancer and cardiovascular disease risk are discussed. Furthermore, the effects of sociocultural risk factors such as minority stress are outlined. In sum, we invite the reader to consider the specific biological, psychological, and social context of the consultation. Finally, we explore culturally competent approaches to pedigree charting and physical examinations with transgender people and provide recommendations for practice.

Vulvodynia Viewed From a Disease Prevention Framework: Insights From Patient Perspectives

INTRODUCTION

Persons with vulvodynia (a chronic vulvar pain condition) suffer many barriers to diagnosis and treatment, several of which may be exacerbated by the sociocultural and geographical context in which they live.

AIM

We drew on the experiences of patients with vulvodynia who were living in small urban and rural communities to learn what they perceived as the major barriers to diagnosis and treatment as well as to probe for possible solutions.

METHODS

For this qualitative case study, we conducted 3 focus groups with a total of 10 participants, drawn from patients seen at our academic tertiary referral center, with a goal of understanding their lived experience with vulvodynia.

MAIN OUTCOME MEASURES

The patient dialogue was coded into themes and temporally grouped to illustrate struggles and victories in diagnosis and treatment.

RESULTS

Participants confirmed that healthcare provider knowledge and attitudes as well as system challenges (specialist and allied healthcare provider availability) are major barriers to timely diagnosis. Of novel interest are other factors that exacerbate distress and delay diagnosis such as patients' inadequate knowledge of sexual functioning and sociocultural messages regarding "normal" sexual activity. Our work suggests that a disease prevention framework that includes comprehensive sexual education before or at the onset of sexual activity may be of benefit in reducing the burden of vulvodynia when added to strategies to increase healthcare provider knowledge and improve access to effective treatments.

CONCLUSION

While healthcare provider knowledge and attitudes are often at the forefront of barriers to diagnosis, our study suggests that to minimize patient distress and expedite diagnosis, resources must also be directed to promoting comprehensive sexual health education. Webber V, Miller ME, Gustafson DL, et al. Vulvodynia Viewed From a Disease Prevention Framework: Insights From Patient Perspectives. Sex Med 2020;8:757-766.

A novel speculum-free imaging strategy for visualization of the internal female lower reproductive system

Fear of the speculum and feelings of vulnerability during the gynecologic exams are two of the biggest barriers to cervical cancer screening for women. To address these barriers, we have developed a novel, low-cost tool called the Callascope to reimagine the gynecological exam, enabling clinician and self-imaging of the cervix without the need for a speculum. The Callascope contains a 2 megapixel camera and contrast agent spray mechanism housed within a form factor designed to eliminate the need for a speculum during contrast agent administration and image capture. Preliminary bench testing for comparison of the Callascope camera to a $20,000 high-end colposcope demonstrated that the Callascope camera meets visual requirements for cervical imaging. Bench testing of the spray mechanism demonstrates that the contrast agent delivery enables satisfactory administration and cervix coverage. Clinical studies performed at Duke University Medical Center, Durham, USA and in Greater Accra Regional Hospital, Accra, Ghana assessed (1) the Callascope's ability to visualize the cervix compared to the standard-of-care speculum exam, (2) the feasibility and willingness of women to use the Callascope for self-exams, and (3) the feasibility and willingness of clinicians and their patients to use the Callascope for clinician-based examinations. Cervix visualization was comparable between the Callascope and speculum (83% or 44/53 women vs. 100%) when performed by a clinician. Visualization was achieved in 95% (21/22) of women who used the Callascope for self-imaging. Post-exam surveys indicated that participants preferred the Callascope to a speculum-based exam. Our results indicate the Callascope is a viable option for clinician-based and self-exam speculum-free cervical imaging.Clinical study registration ClinicalTrials.gov https://clinicaltrials.gov/ct2/show/record/ NCT00900575, Pan African Clinical Trial Registry (PACTR) https://www.pactr.org/ PACTR201905806116817.

Cervical cancer prevention in transgender men: a review

There is increased awareness of transgender physical and mental health widely and in academic research. A significant proportion of transgender men will retain their cervix with an increased risk of cervical cancer. In this review of cervical cancer screening among transgender men, we try to estimate how many transgender men still have a cervix, understand to identify challenges and barriers to cervical screening and propose possible solutions. Organised cervical screening programmes need to consider the needs of this population, in particular the provision of HPV self-sampling. TWEETABLE ABSTRACT: Transgender men need access to cervical screening.

Clinical needs for transgender men in the gynecologic oncology setting

Transgender men remain at risk for gynecologic malignancies, but are an underserved population. Members of the transgender community experience discrimination and have experiences that contribute to health disparities, including in gynecology and oncology. While efforts have been made within the United States to reduce inequalities experienced by members of this community, many needs in the clinical setting remain. Increased education and training among providers and healthcare professionals, and general improvements towards understanding barriers to health screening and health resource uptake may reduce some disparities. Additional research towards screening and cancer surveillance among this community will be necessary to understand any potential additional risks and survival disparities experienced by transgender men. This review focuses on barriers and clinical needs for transgender men in the gynecologic oncology setting, and suggestions for moving forward to improve care for this patient population.

Providing Care for Transgender and Gender Diverse Youth

Transgender and gender diverse youth (TGDY) experience modifiable health disparities and difficulty accessing the physical and mental health care systems. Providers and staff should understand the unique needs of this population and provide affirming spaces where these resilient young people can thrive. In addition to addressing social, setting, and system level barriers to access, providers should consider offering comprehensive gender care because this reduces barriers to medical services and can improve health outcomes. This article educates providers about TGDY, reviews the role of mental health care, and provides an overview of medical interventions for gender affirmation.

Gender affirming medical care of transgender youth

The number of gender diverse and transgender youth presenting for treatment are increasing. This is a vulnerable population with unique medical needs; it is essential that all pediatricians attain an adequate level of knowledge and comfort caring for these youth so that their health outcomes may be improved. There are several organizations which provide clinical practice guidelines for the treatment of transgender youth including the WPATH and the Endocrine Society and they recommend that certain eligibility criteria should be met prior to initiation of gender affirming hormones. Medical intervention for transgender youth can be broken down into stages based on pubertal development: pre-pubertal, pubertal and post-pubertal. Pre-pubertally no medical intervention is recommended. Once puberty has commenced, youth are eligible for puberty blockers; and post-pubertally, youth are eligible for feminizing and masculinizing hormone regimens. Treatment with gonadotropin releasing hormone agonists are used to block puberty. Their function is many-fold: to pause puberty so that the youth may explore their gender identity, to delay the development of (irreversible) secondary sex characteristics, and to obviate the need for future gender affirmation surgeries. Masculinizing hormone regimens consists of testosterone and feminizing hormone regimens consist of both estradiol as well as spironolactone. In short term studies gender affirming hormone treatment with both estradiol and testosterone has been found to be safe and improve mental health and quality of life outcomes; additional long term studies are needed to further elucidate the implications of gender affirming hormones on physical and mental health in transgender patients. There are a variety of surgeries that transgender individuals may desire in order to affirm their gender identity; it is important for providers to understand that desire for medical interventions is variable among persons and that a discussion about individual desires for surgical options is recommended.

Gynecologic Health Care Providers' Willingness to Provide Routine Care and Papanicolaou Tests for Transmasculine Individuals

Background: Transmasculine individuals who have a cervix may be at risk of cervical cancer, but they face a number of barriers to accessing care, including difficulty finding knowledgable and culturally sensitive providers who are willing to care for transgender patients. We examined gynecologic health care providers' willingness to provide routine care and Papanicolaou tests (Pap tests) to transmasculine individuals, including the role of personal, clinical, and professional factors. Materials and Methods: We surveyed attending physicians, advanced practitioners, and residents in the Women's Health department of a large, integrated Midwest health system (n = 60, 74.1% response rate). Results: A majority of participants were female (68.3%) and white (73.3%). Most had met a transgender person before (79.7%), and 40.7% had cared for a transgender patient in the past 5 years. Most reported willingness to provide routine care (74.6%) and Pap tests (85.0%) to transmasculine people. Bivariate analysis suggests that having met a transgender person (p = 0.028), higher empathy scores (p = 0.015), political views (p = 0.0130), and lower transphobia (p = 0.012) were associated with willingness to provide routine care to transmasculine individuals. Lower transphobia (p = 0.034) and political views (p < 0.001) were also associated with willingness to provide Pap tests to transmasculine people. Conclusions: Providers' willingness was not associated with barriers related to training or knowledge-only with personal biases and experiences. Transgender-inclusive health care training that addresses personal attitudes should be a routine part of training for all health professionals.

Advances in technologies for cervical cancer detection in low-resource settings

Introduction: Cervical cancer mortality rates remain high in low- and middle-income countries (LMICs) and other medically underserved areas due to challenges with implementation and sustainability of routine screening, accurate diagnosis, and early treatment of preinvasive lesions. Areas covered: In this review, we first discuss the standard of care for cervical cancer screening and diagnosis in high- and low-resource settings, biomarkers that correlate to cervical precancer and cancer, and needs for new tests. We review technologies for screening and diagnosis with a focus on tests that are already in use in LMICs or have the potential to be adapted for use in LMICs. Finally, we provide perspectives on the next five years of technology development for improved cervical cancer screening and diagnosis in LMICs. Expert opinion: Innovation toward improved molecular and imaging tests is needed to enable effective, affordable see-and-treat approaches to detect and treat cervical precancer in a single visit. Current molecular tests remain too complex and/or costly for widespread use. Especially with imaging tests, decision support may improve performance of new technologies.