Test performance and acceptability of self- versus provider-collected swabs for high-risk HPV DNA testing in female-to-male trans masculine patients

Breast and cervical cancer in transgender men: literature review and a case report

Transgender individuals exhibit a higher prevalence of cancer-related risk factors, such as substance abuse and sexually transmitted infections. These factors, coupled with suboptimal adherence to cancer screening recommendations, may lead to a higher incidence of cancers, such as breast and cervical cancer, and contribute to delayed diagnoses in transgender patients. Herein, we report a unique case of a transgender man with a history of alcohol and drug abuse, undergoing gender-affirming exogenous testosterone therapy, who developed synchronous locally advanced breast cancer and human papilloma virus (HPV)-related cervical cancer. He underwent concurrent chemoradiation for cervical cancer and surgery followed by endocrine therapy for breast cancer. The treatments were suboptimals due to patient's comorbidities, among them liver cirrhosis leading to an early death. Additionally, we have conducted a review of existing literature, including case reports, clinical studies, and review articles investigating the role of potential risk factors specifically related to breast and cervical tumors in transgender men. Gender-affirming testosterone therapy is common among transgender men to induce gender affirmation, but its link to breast cancer risk remains ambiguous, with studies being limited and sometimes contradictory. Conversely, HPV is a well-established cause of up to 99% of cervical cancers. Despite persistent risk for cervical cancer in transgender men who retain their cervix, several studies indicate notable disparities in screening adherence, due to personal and structural barriers. Moreover, alcohol and drug use disorders, commonly encountered in transgender population, may negatively influence the adherence to screening programs. Current cancer screening guidelines for this population are somewhat unclear, and specific programs based on more robust data are urgently required along with further tailored studies.

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.

Cancer screening attendance rates in transgender and gender-diverse patients: a systematic review and meta-analysis

OBJECTIVES

To examine disparities in attendance rates at cancer screening services between transgender and gender-diverse (TGD) people in comparison with their cisgender (CG) counterparts, and to determine whether these differences were based on the anatomical organ screened.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, EMBASE (via Ovid), CINAHL Complete (via EBSCO) and Cochrane Library from inception to 30 September 2023.

METHODS

Studies for inclusion were case-control or cross-sectional studies with quantitative data that investigated TGD adults attending any cancer screening service. Exclusion criteria were studies with participants who were ineligible for cancer screening or without samples from TGD individuals, qualitative data and a cancer diagnosis from symptomatic presentation or incidental findings. A modified Newcastle-Ottawa Scale was used to assess risk of bias, during which seven reports were found incompatible with the inclusion criteria and excluded. Results were synthesised through random-effects meta-analysis and narrative synthesis.

RESULTS

We identified 25 eligible records, of which 18 were included in the analysis. These were cross-sectional studies, including retrospective chart reviews and survey analyses, and encompassed over 14.8 million participants. The main outcomes measured were up-to-date (UTD) and lifetime (LT) attendance. Meta-analysis found differences for UTD cervical (OR 0.37, 95% CI 0.23 to 0.60, p<0.0001) and mammography (OR 0.41, 95% CI 0.20 to 0.87, p=0.02) but not for prostate or colorectal screening. There were no meaningful differences seen in LT attendance based on quantitative synthesis. Narrative synthesis of the seven remaining articles mostly supported the meta-analysis. Reduced rates of screening engagement in TGD participants were found for UTD cervical and mammography screening, alongside LT mammography screening.

CONCLUSIONS

Compared with their CG counterparts, TGD individuals had lower rates of using cervical and mammography screening at the recommended frequencies but displayed similar prevalences of LT attendance. The greatest disparity was seen in UTD cervical screening. Limitations of this review included high risk of bias within studies, high heterogeneity and a lack of resources for further statistical testing. Bridging gaps in healthcare to improve cancer screening experiences and outcomes will require consolidated efforts including working with the TGD community.

PROSPERO REGISTRATION NUMBER

CRD42022368911.

Rationale and design of the Self-TI Study protocol: a cross-sectional human papillomavirus self-testing pilot study among transgender adults in England

INTRODUCTION

Persistent infection with high-risk human papillomavirus (HPV) is the causal agent of several cancers including cervical, anal and oropharyngeal cancer. Transgender men and transmasculine non-binary (TMNB) people with a cervix are much less likely to undergo cervical cancer screening than cisgender women. Transgender women and transfeminine non-binary (TWNB) people assigned male at birth may be at increased risk of HPV. Both TMNB and TWNB people face many barriers to HPV testing including medical mistrust due to stigma and discrimination.

METHODS AND ANALYSIS

The Self-TI Study (Self-TI) is a pilot study designed to measure acceptability and feasibility of HPV self-testing among transgender and non-binary people in England. TMNB people aged 25-65 years, with at least 1 year of testosterone, and TWNB people, aged 18 years and over, are eligible to participate. Participants self-collect up to four samples: an oral rinse, a first void urine sample, a vaginal swab (if applicable) and an anal swab. TMNB participants are asked to have an additional clinician-collected cervical swab taken following their routine Cervical Screening Programme sample. TWNB people are asked to take a self-collection kit to perform additional self-collection at home and mail the samples back to the clinic. Acceptability is assessed by a self-administered online survey and feasibility is measured as the proportion of samples returned in the clinic and from home.

ETHICS AND DISSEMINATION

Self-TI received ethical approval from the Research Ethics Committee of Wales 4 and ethical review panel within the Division of Cancer Epidemiology and Genetics at the US National Cancer Institute. Self-TI was coproduced by members of the transgender and non-binary community, who served as authors, collaborators and members of the patient and public involvement (PPI) group. Results of this study will be shared with the community prior to being published in peer-reviewed journals and the PPI group will help to design the results dissemination strategy. The evidence generated from this pilot study could be used to inform a larger, international study of HPV self-testing in the transgender and non-binary community.

TRIAL REGISTRATION NUMBER

NCT05883111.

Sexual Health for Transgender and Gender Diverse Individuals: Routine Examination, Sexually-Transmitted Infection Screening, and Prevention

Gynecologists play a critical role in the office evaluation of transgender and gender diverse individuals. This includes the provision of essential healthcare services including the treatment and prevention of human immunodeficiency virus and sexually-transmitted infections and screening for human papillomavirus infection-related diseases and cancers. Caring for patients who identify as transgender or gender diverse (TGD) and who have undergone gender-affirming surgical treatments is challenging due in part to clinical gaps in knowledge resulting from insufficient training and educational resources. A patient-centered approach to the care of TGD individuals requires knowledge of the general principles of affirming, holistic care with attention to the risk factors, and anatomic considerations unique to this population. This review aims to provide basic knowledge needed for the successful gynecologic evaluation of a gender diverse patient.

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.

Breast and cervical cancer screenings across gender identity: results from the Behavioral Risk Factor Surveillance System before and during the COVID-19 pandemic

PURPOSE

Although national medical organizations often neglect to include trans and gender diverse (TGD) people in their breast and cervical cancer screening recommendations, the World Profession Association of Transgender Health recommends that TGD people who are at risk for these cancers follow existing guidelines for cisgender women. Despite WPATH's recommendations, TGD people are less likely to get screened in large part due to discrimination. The COVID-19 pandemic has limited access to cancer screenings among cisgender people, but it is unknown how this has impacted TGD people.

METHODS

Using national survey data from the Behavioral Risk Factors Surveillance System (BRFSS), we examined differences in cervical and breast cancer screening noncompliance across gender identity at two time points: before and during the COVID-19 pandemic.

RESULTS

Screening noncompliance increased during the COVID-19 pandemic among cisgender and TGD people (e.g., transgender men, gender non-conforming people). Compared to cisgender women, transgender men and gender non-conforming respondents had higher odds of breast cancer screening noncompliance before and during COVID-19. Transgender men had lower odds of cervical cancer screening noncompliance than cisgender women before COVID-19, but higher odds during the pandemic. Gender non-conforming respondents also had lower odds of cervical cancer screening noncompliance during COVID-19 compared to cisgender women.

CONCLUSIONS

Screening noncompliance for breast and cervical cancer was more common among TGD people than cisgender women; while these disparities existed before the COVID-19 pandemic, they were exacerbated during the pandemic. Future work should move beyond descriptive statistics and elucidate underlying causes to inform interventions.

Primary Care and Health Care of Transgender and Gender-Diverse Older Adults

Clinicians working with older transgender and gender-diverse (TGD) individuals need to acquire the necessary knowledge and skills to provide care that is high quality and culturally appropriate. This includes supporting patients in their exploration of gender and attainment of gender-affirming medical interventions. Clinicians should strive to create environments that are inclusive and safe, and that will facilitate health care access and build constructive provider-patient relationships. Clinicians should be aware of best practices, including that age-appropriate health screenings should be anatomy based, and ensure that TGD older adults on gender-affirming hormone therapy (GAHT) receive ongoing laboratory monitoring and physical assessments, including serum hormone levels and biomarkers. Older TGD adults underutilize advance care planning, and need individualized assessments that consider their unique family structures, social support, and financial situation. End-of-life care services should ensure that TGD individuals are treated with dignity and respect.

Gender-Affirming Hormone Therapy and Cervical Cancer Screening Rates in Transgender Men and Nonbinary People: A Cross-Sectional Study from a Boston Community Health Center

Purpose: Clinical monitoring for patients receiving gender-affirming hormone therapy (GAHT) has the potential to facilitate their receipt of preventive health services. We aimed to determine whether GAHT is associated with increased utilization of cervical cancer screening among transgender men (TM) and nonbinary persons assigned female at birth (NB-AFAB). Methods: We conducted a cross-sectional observational study of a single community health center in Boston. Persons of all gender identities eligible for cervical cancer screening during 2008-2019 were assessed. The outcome of interest was receipt of cervical cancer screening based on U.S. Preventive Services Task Force recommendations. We compared the proportion of persons who received cervical cancer screening by prescription of GAHT. Results: We identified 13,267 eligible persons. This cohort included 10,547 (79.5%) cisgender women, 1547 (11.7%) TM, and 1173 (8.8%) NB-AFAB persons. Among all persons eligible for cervical cancer screening, TM and NB-AFAB persons were less likely to receive screening than cisgender women (56.2% and 56.1% vs. 60.5% respectively; odds ratio [OR] = 0.84; 95% confidence interval [CI] = 0.75-0.93; OR = 0.84; 95% CI = 0.74-0.94, respectively). Among TM, those prescribed testosterone were more likely to receive cervical cancer screening than those not prescribed testosterone (57.9% vs. 48.2%, OR = 1.47; 95% CI = 1.14-1.92). Among NB-AFAB adults, those prescribed testosterone were more likely to receive cervical cancer screening than those not prescribed testosterone (61.9% vs. 51.5%, OR = 1.53; 95% CI = 1.21-1.93). Conclusions: The benefits of engagement in care to access GAHT may extend beyond the hormonal intervention to preventive health services.

Characteristics of Clinicians Caring for Transgender Men and Nonbinary Individuals and Guideline Concordance of Clinicians' Cervical Cancer Screening Counseling for Cisgender Individuals Versus Transgender Men and Nonbinary Individuals with a Cervix

Purpose: We examined characteristics of clinicians caring for transgender men and nonbinary (TMNB) individuals and guideline concordance of clinicians' cervical cancer screening recommendations. Methods: Using a survey of clinicians who performed ≥10 cervical cancer screenings in 2019, we studied characteristics of clinicians who do versus do not report caring for TMNB individuals and guideline concordance of screening recommendations for TMNB individuals with a cervix versus cisgender women. Results: In our sample (N = 492), 49.2% reported caring for TMNB individuals, and 25.4% reported performing cervical cancer screening for TMNB individuals with a cervix. Differences in guideline concordance of screening recommendations for TMNB individuals with a cervix versus cisgender women (45.8% vs. 50% concordant) were not statistically significant. Conclusion: Sizable proportions of clinicians cared for and performed cervical cancer screening for TMNB individuals. Research is needed to better understand clinicians' identified knowledge deficits to develop interventions (e.g., clinician trainings) to improve gender-affirming cervical cancer prevention.

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.

Facilitating Gender-Affirming Nursing Encounters

The purpose of this article is to highlight the essentials for facilitating gender-affirming nursing encounters for transgender, nonbinary, and other gender expansive (TNGE) people. The authors illustrate what constitutes as gender-affirming nursing encounters by characterizing gender-affirming approaches to conducting and documenting a nursing assessment and describing techniques to overcome institutional-level challenges that may hinder a nurse's ability to establish gender-affirming therapeutic relationships with TNGE people. The authors also provide strategies that nurses can use to improve their health care organization and interprofessional collaborative practice to create psychologically and physically safe health care spaces for TNGE people.

Sexual Health Care for Transgender and Gender Diverse People

The proportion of people who identify as transgender and gender diverse (TGD) is increasing. Health care for TGD people, including sexual health care, must affirm and respect patients' gender identities and expressions. Here, the authors outline strategies to make health care settings more welcoming to and inclusive of TGD people and describe concrete steps to improve sexual health care for TGD populations.

Concordance of Primary Human Papillomavirus Testing Among Clinicians and Patients: A Systematic Review

Objective: Primary high risk human papilloma virus (hrHPV) testing is recommended as first-line screening for cervical cancer. Testing involves either a clinician-collected or a self-collected cervicovaginal swab. This study examines concordance between methods of collection of primary HPV testing. Methods: Ovid MEDLINE, Ovid Embase, and Cochrane were searched for relevant studies on self-collected and clinician-collected primary HPV testing published before December 31, 2022. English-language studies for primary HPV testing of average-risk patients were included. Studies conducted in screening settings rather than colposcopy clinics, that used standard devices for HPV collection, and that directly compared methods of collection were included. Outcomes were concordance and kappa between paired samples, and rate of HPV detection in self-collected and clinician-collected samples. Results: A total of 2381 studies were screened, of which 228 were included for full-text evaluation. Thirty-six studies, including 23,328 individuals screened, met the inclusion criteria. The rate of HPV detection ranged from 4.7% to 63% for self-collection and from 3.7% to 62% for clinician-collection. The concordance ranged from 78.2% to 96.9%, and kappa had substantial agreement for 26 of the 36 studies and moderate agreement for 7 of the 36 studies. Conclusions: This study directly compares clinician-collected and self-collected primary HPV screening rates. Studies were conducted in methods which are widely reproducible in the primary care setting. Primary HPV self-collection is a reliable and accurate method for cervical cancer screening.

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.

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.

Clinical Performance of Cobas 6800 for the Detection of High-Risk Human Papillomavirus in Urine Samples

Testing for high-risk human papillomavirus (HPV) as part of primary cervical cancer screening has become more common recently. The Cobas 6800, an FDA-approved cervical screening platform, detects 14 high-risk HPVs, including HPV16 and HPV18. However, this test is limited to only women, which leads to low screening rates in trans men and other non-binary people. The cervical screening of trans men and other genders, especially those lying on the female-to-male spectrum, is equally important. Furthermore, cisgender males, particularly homosexuals, are also prone to chronic HPV infections and serve as HPV carriers, transmitting it to women and other men through sexual contact. Another limitation of the test is its invasive specimen collection, which induces discomfort and genital dysphoria. Therefore, there is a need for an innovative, less invasive method that would allow the sampling process to be more comfortable. In this study, we assess the performance of the Cobas 6800 for high-risk HPV detection in urine samples spiked with HPV16, HPV18, and HPV68. The limit of detection (LOD) was calculated using a dilution series (1.25-10,000 copies/mL) over a course of three days. Furthermore, the clinical validation was performed by calculating sensitivity, specificity, and accuracy. The limit of detection ranged from 50-1000 copies/mL depending upon the genotype. Moreover, the urine test demonstrated a high clinical sensitivity of 93%, 94%, and 90% for HPV16, HPV18, and HPV68, with 100% specificity. The overall percent agreement was calculated to be 95% for both HPV16 and HPV18, and 93% for HPV68. The high concordance, reproducibility, and clinical performance of the current assay suggest that the urine-based HPV test fulfills the requirements for its use in primary cervical screening. Moreover, it has the potential to be used for mass screening to not only identify high-risk individuals, but also to monitor vaccine effectiveness.

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.

Digital-Assisted Self-interview of HIV or Sexually Transmitted Infection Risk Behaviors in Transmasculine Adults: Development and Field Testing of the Transmasculine Sexual Health Assessment

BACKGROUND

The sexual health of transmasculine (TM) people-those who identify as male, men, or nonbinary and were assigned a female sex at birth-is understudied. One barrier to conducting HIV- and sexually transmitted infection (STI)-related research with this population is how to best capture sexual risk data in an acceptable, gender-affirming, and accurate manner.

OBJECTIVE

This study aimed to report on the community-based process of developing, piloting, and refining a digitally deployed measure to assess self-reported sexual behaviors associated with HIV and STI transmission for research with TM adults.

METHODS

A multicomponent process was used to develop a digital-assisted self-interview to assess HIV and STI risk in TM people: gathering input from a Community Task Force; working with an interdisciplinary team of content experts in transgender medicine, epidemiology, and infectious diseases; conducting web-based focus groups; and iteratively refining the measure. We field-tested the measure with 141 TM people in the greater Boston, Massachusetts area to assess HIV and STI risk. Descriptive statistics characterized the distribution of sexual behaviors and HIV and STI transmission risk by the gender identity of sexual partners.

RESULTS

The Transmasculine Sexual Health Assessment (TM-SHA) measures the broad range of potential sexual behaviors TM people may engage in, including those which may confer risk for STIs and not just for HIV infection (ie, oral-genital contact); incorporates gender-affirming language (ie, genital or frontal vs vaginal); and asks sexual partnership characteristics (ie, partner gender). Among 141 individual participants (mean age 27, SD 5 years; range 21-29 years; n=21, 14.9% multiracial), 259 sexual partnerships and 15 sexual risk behaviors were reported. Participants engaged in a wide range of sexual behaviors, including fingering or fisting (receiving: n=170, 65.6%; performing: n=173, 66.8%), oral-genital sex (receiving: n=182, 70.3%; performing: n=216, 83.4%), anal-genital sex (receptive: n=31, 11.9%; insertive: n=9, 3.5%), frontal-genital sex (receptive: n=105, 40.5%; insertive: n=46, 17.8%), and sharing toys or prosthetics during insertive sex (n=62, 23.9%). Overall barrier use for each sexual behavior ranged from 10.9% (20/182) to 81% (25/31). Frontal receptive sex with genitals and no protective barrier was the highest (21/42, 50%) with cisgender male partners. In total, 14.9% (21/141) of participants reported a lifetime diagnosis of STI. The sexual history tool was highly acceptable to TM participants.

CONCLUSIONS

The TM-SHA is one of the first digital sexual health risk measures developed specifically with and exclusively for TM people. TM-SHA successfully integrates gender-affirming language and branching logic to capture a wide array of sexual behaviors. The measure elicits sexual behavior information needed to assess HIV and STI transmission risk behaviors. A strength of the tool is that detailed partner-by-partner data can be used to model partnership-level characteristics, not just individual-level participant data, to inform HIV and STI interventions.

Cancer in Transgender and Gender-Diverse Persons: A Review

Importance

Transgender and gender-diverse individuals face unique challenges, including barriers to health care access and inequities in treatment, that may influence cancer risk and outcomes.

Observations

In this narrative review, a scoping review was conducted focusing on primary and secondary prevention and epidemiology of cancer, barriers to health care services, and health care practitioners' knowledge about specific issues pertaining to transgender and gender-diverse individuals. PubMed, the Cochrane Library, and Embase, were reviewed for citations from their inception to December 31, 2021. This review revealed that transgender and gender-diverse people had a high prevalence of tobacco consumption and alcohol use and high rates of infection with human papillomavirus (HPV) and HIV. Transgender and gender-diverse individuals were less likely to adhere to cancer screening programs and had a higher incidence of HIV- and HPV-associated cancers. Social and economic determinants seemed to drive these disparities in risk factors and outcomes. A lack of knowledge about gender minorities' health needs among health care practitioners was evidenced, and it represented a major hurdle to cancer prevention, care, and survivorship for transgender and gender-diverse individuals. Discrimination, discomfort caused by gender-labeled oncological services, stigma, and lack of cultural sensitivity of health care practitioners were other barriers met by transgender and gender-diverse persons in the oncology setting.

Conclusions and Relevance

The findings suggest that transgender and gender-diverse peoples' needs in the cancer care continuum are not optimally addressed. Effective solutions are needed to offer the best care to every patient in a person-centric and gender diversity-sensitive environment.

Gender-affirming hormonal therapy for transgender and gender-diverse people-A narrative review

As the number of transgender and gender-diverse (TGD) people accessing gender-affirming care increases, the need for healthcare professionals (HCPs) providing gender-affirming hormonal therapy (GAHT) also increases. This chapter provides an overview of the HCPs interested in getting involved in providing GAHT.

Factors Associated with Unsatisfactory Pap Tests Among Sexually Active Trans Masculine Adults

Purpose: Unsatisfactory collection of cells during Papanicolaou (Pap) tests prevents the detection of cervical cancer and dysplasia. Prior research found that trans masculine (TM) individuals are significantly more likely than cisgender women to have an unsatisfactory Pap test. The purpose of this study was to identify factors that place some TM individuals at greater risk for an unsatisfactory Pap test than others. Methods: Between 2015 and 2016, 150 TM adults were enrolled in a cross-sectional survey assessing demographics, health characteristics, health care experiences, trauma history, and unsatisfactory Pap test history. Bivariate and multivariable logistic regression analyses conducted in 2020 examined associations between age, length of time on testosterone, smoking history, having to educate a provider about transgender people to receive appropriate care, anticipated health care stigma, post-traumatic stress disorder (PTSD) symptoms, and lifetime history of unsatisfactory Pap tests. Results: Of all participants, 20.2% had an unsatisfactory test in their lifetime, age ranged from 21 to 50 years, 55.1% used testosterone for 1 year or more, and 41.3% had PTSD symptoms. In the multivariable model, older age (adjusted odds ratio [AOR] = 1.15; 95% confidence interval (CI) = 1.04-1.27; p < 0.01), 1 year or more lifetime testosterone use (AOR = 3.51; 95% CI = 1.02-12.08; p = 0.046), and PTSD symptoms (AOR = 3.48; 95% CI = 1.10-11.00, p = 0.03) were significantly associated with increased odds of having an unsatisfactory Pap test. Conclusions: Older age, testosterone use, and PTSD symptoms are associated with lifetime unsatisfactory Pap tests among TM adults. Clinicians should assess TM patients' trauma and testosterone use history before Pap tests and utilize trauma-informed practices that facilitate the collection of adequate Pap samples.

La santé sexuelle des hommes trans : entre problèmes de catégorisation et invisibilisation

INTRODUCTION

Sexual minorities have been disproportionally impacted by the HIV-Aids epidemic. Their high prevalence motivated sexual health research that first focused on gay men, then trans women. Trans men have been considered at very low risk of exposition, Hence the scarce number of research about them. However, an emerging literature is showing diversified and surprising results regarding the reasons for their initial exclusion.

PURPOSE OF RESEARCH

This article seeks to establish the state of knowledge on trans men's sexual health through a French and international literature review.

RESULTS

Trans men have a variety of partners, sexual and non-sexual practices (IDU) that leads to categorize them at high risk of HIV exposure. The proportion of trans men who are HIV positive still is difficult to assess. It is estimated to be high in the USA, and close to zero in France. Low screening rates, difficulties accessing health care, and identification problems in the very classification of people suggest that they might be more of them. Trans men also report discriminations in access to health care services, and specific health vulnerabilities. Gynecology and reproductive health are rarely even mentioned.

CONCLUSIONS

Rethinking the categories used in research would produce a more accurate representation of the varied realities of trans people.

Gender-affirming hormone therapy, mental health, and surgical considerations for aging transgender and gender diverse adults

As the transgender and gender diverse (TGD) population ages, more transfeminine and transmasculine individuals present to clinic to initiate or continue their gender-affirming care at older ages. Currently available guidelines on gender-affirming care are excellent resources for the provision of gender-affirming hormone therapy (GAHT), primary care, surgery, and mental health care but are limited in their scope as to whether recommendations require tailoring to older TGD adults. Data that inform guideline-recommended management considerations, while informative and increasingly evidence-based, mainly come from studies of younger TGD populations. Whether results from these studies, and therefore recommendations, can or should be extrapolated to aging TGD adults remains to be determined. In this perspective review, we acknowledge the lack of data in older TGD adults and discuss considerations for evaluating cardiovascular disease, hormone-sensitive cancers, bone health and cognitive health, gender-affirming surgery, and mental health in the older TGD population on GAHT.

HPV screening in the urine of transpeople - A prevalence study

BACKGROUND

There is limited data on human papillomaviruses (HPV) prevalence in transpeople due to low acceptance rate of screening methods. HPV tests from self-collected urine are gender-neutral, have a high acceptance, and have a comparable accuracy in females to clinician-collected samples. The aim of this study was to evaluate both the HPV prevalence in the urine in a large cohort of 200 transpeople with common risk profiles and the acceptability of such screening method.

METHODS

The study was conducted at the outpatient clinic for transpeople at the Department of Obstetrics and Gynaecology, Medical University of Vienna, Austria. 200 transpeople have been enrolled between May and October 2021. Inclusion criteria were gender identity dysphoria, age over 18 years, and adequate language skills.Subjects were asked to answer a survey concerning gender identity, established risk factors for HPV infections as well as their preference regarding urine or provider-collected cytology-/HPV-based screening, and to provide a urine sample. Five patients not able to provide urine were excluded. HPV genotyping was performed using a validated multiplex real-time PCR assay, which simultaneously detects 28 HPV genotypes. This trial is registered at ClinicalTrials.gov, NCT04864951.

FINDINGS

Overall HPV positivity was 19·0% (37/195), 24·2% in female to male, 11·8% in male to female, 26·3% in genderqueer/non binary/other subjects, 27·9% in subjects currently having a cervix, and 26·0% in subjects born with cervix. Independent of gender reassignment surgery, being born with a cervix was associated with a higher risk of HPV infections (p = 0·008), yet 42·3% (44/104) have never attended cervical cancer screening. Overall, 79·0% (154/195) of transpeople would prefer urine HPV tests to provider-collected HPV screening.

INTERPRETATION

HPV testing in self-collected urine samples provides a unique opportunity for screening of this hard-to-reach population and should be evaluated in further studies.

FUNDING

None.

Cervicovaginal cytology, HPV testing and vaginal flora in transmasculine persons receiving testosterone

BACKGROUND

Testosterone is one of the strategies that transmasculine persons can elect in order to align physical traits to their gender identity. Previous studies have shown morphologic changes in the genital tract associated with testosterone. Here, we aim to evaluate cervicovaginal cytology specimens (Pap tests) and high-risk HPV (HR-HPV) testing from transmasculine individuals receiving testosterone.

METHODS

This is a retrospective cohort of 61 transmasculine individuals receiving testosterone from 2013 to 2021. Cytologic diagnoses from 65 Pap tests were correlated with HPV status and histologic follow-up and compared with the institutional data and a cohort of cisgender women with atrophic changes.

RESULTS

The median age was 28 years and median time of testosterone use was 3 years. Transmasculine persons showed significantly higher rates of HSIL (2%) and unsatisfactory (16%) when compared with the institutional data and atrophic cohort of cisgender women. After reviewing slides of 46 cases, additional findings were noted: atrophy was present in 87%, glycogenated cells were seen in 30%, and Lactobacilli were substantially decreased in 89%. Among 32 available HPV tests, 19% were positive for HR-HPV and 81% were negative. On histologic follow-up, all HR-HPV-positive cases with abnormal cytology showed HSIL, while none of the HPV-negative cases revealed HSIL.

CONCLUSION

Our study cohort demonstrated a high percentage of abnormal Pap tests in transmasculine persons receiving testosterone. Testosterone seems to induce changes in squamous cells and shifts in vaginal flora. HR-HPV testing can be a useful adjunct in the workup of abnormal Pap tests from transmasculine individuals.

Standards of Care for the Health of Transgender and Gender Diverse People, Version 8

Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.

Secondary Prevention of Cervical Cancer: ASCO Resource-Stratified Guideline Update

PURPOSE

To update resource-stratified, evidence-based recommendations on secondary prevention of cervical cancer globally.

METHODS

American Society of Clinical Oncology convened a multidisciplinary, multinational Expert Panel to produce recommendations reflecting four resource-tiered settings. A review of existing guidelines, formal consensus-based process, and modified ADAPTE process to adapt existing guidelines was conducted. Other experts participated in formal consensus.

RESULTS

This guideline update reflects changes in evidence since the previous update. Five existing guidelines were identified and reviewed, and adapted recommendations form the evidence base. Cost-effectiveness analyses provided indirect evidence to inform consensus, which resulted in ≥ 75% agreement.

RECOMMENDATIONS

Human papillomavirus (HPV) DNA testing is recommended in all resource settings; visual inspection with acetic acid may be used in basic settings. Recommended age ranges and frequencies vary by the following setting: maximal: age 25-65 years, every 5 years; enhanced: age 30-65 years, if two consecutive negative tests at 5-year intervals, then every 10 years; limited: age 30-49 years, every 10 years; basic: age 30-49 years, one to three times per lifetime. For basic settings, visual assessment is used to determine treatment eligibility; in other settings, genotyping with cytology or cytology alone is used to determine treatment. For basic settings, treatment is recommended if abnormal triage results are obtained; in other settings, abnormal triage results followed by colposcopy is recommended. For basic settings, treatment options are thermal ablation or loop electrosurgical excision procedure; for other settings, loop electrosurgical excision procedure or ablation is recommended; with a 12-month follow-up in all settings. Women who are HIV-positive should be screened with HPV testing after diagnosis, twice as many times per lifetime as the general population. Screening is recommended at 6 weeks postpartum in basic settings; in other settings, screening is recommended at 6 months. In basic settings without mass screening, infrastructure for HPV testing, diagnosis, and treatment should be developed.Additional information is available at www.asco.org/resource-stratified-guidelines.

Cytology and LGBT+ health: establishing inclusive cancer screening programs

There are substantial disparities in cancer screening for sexual minorities and gender non-conforming patients. In additional to patients having trauma due to negative experiences with the healthcare system, disparities may be heightened due to heteronormative and cisnormative design of screening programs and electronic medical record systems. Furthermore, there are morphologic challenges specific to certain specimen types from the LGBT + population, such as anal cytology samples, cervical cytology from transgender men taking testosterone, and neovaginal cytology samples. Men who have sex with men are at increased risk for anal cancer compared with the general population. While early detection of anal dysplasia decreases the risk of invasive carcinoma, screening programs are not widespread. Cervical cancer screening may be psychologically and physically challenging for transgender men and non-binary patients. The use of exogenous testosterone therapy causes atrophic changes in cervical cytology samples which mimic high-grade dysplasia. The rate of unsatisfactory samples are also increased in this population. Although HPV driven cancers have been reported in patients with neovaginas, there are currently no guidelines about appropriate screening for transgender women and intersex patients who have neovaginas. Cytopathologists can optimize the health of LGBT + patients in many ways including advocating for inclusive screening guidelines, validating self-collection for HPV and cytology samples, updating requisition forms to better capture the spectrum of gender expression, and recognizing the morphologic changes in cytology samples due to exogenous hormone use.

Health Insurance Prevalence Among Gender Minority People: A Systematic Review and Meta-Analysis

Purpose

Gender minority (GM) (people whose gender does not align with the sex assigned at birth) people have historically been insured at lower rates than the general population. The purpose of this review is to (1) assess the prevalence of health insurance among GM adults in the United States, (2) examine prevalence by gender, and (3) examine trends in prevalence before and after implementation of the Affordable Care Act.

Methods

Published articles from PubMed, EMBASE, and Web of Science databases before April 26th, 2019, were included. This review is registered on PROSPERO (CRD42019133627). Analysis was guided by a random-effects model to obtain a meta-prevalence estimate for all GM people and stratified by gender subgroup. Heterogeneity was assessed using a Q-test and I 2 measure.

Results

Of 55 included articles, a random pooled estimate showed that 75% GM people were insured (95% confidence interval [CI]: 0.71-0.79; p<0.001). Subgroup analysis by gender determined 70% of transgender women (95% CI: 0.64-0.76; p<0.001; I 2=97.16%) and 80% of transgender men (95% CI: 0.77-0.83; p=0.01; I 2=54.51%) were insured. Too few studies provided health insurance prevalence data for gender-expansive participants (GM people who do not identify as solely man or woman) to conduct analysis.

Conclusion

The pooled prevalence of health insurance among GM people found in this review is considerably lower than the general population. Standardized collection of gender across research and health care will improve identification of vulnerable individuals who experience this barrier to preventative and acute care services.

"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.

'Poorly relaxed women': A situational analysis of pelvic examination learning materials for medical students

BACKGROUND

Certain clinical pelvic examination (PE) teaching methods have been critiqued for prioritising student learning over patient autonomy and for not accurately representing diverse patient communities. As such, patient-centred and culturally competent approaches to the PE may need further emphasis in the medical curriculum-in particular, in content delivered to students before patient interaction. Classroom materials serve as students' first exposure to the sensitive procedure. This research explores how patients are represented in these materials.

METHODS

A situational analysis was conducted on 10 purposively sampled PE learning materials for the 2019/20 academic year from five undergraduate medical schools in Canada. Situational analysis focuses on analysing discourse but is epistemically aligned with post-structuralism (most notably Foucault's theories involving discursive power) and allows for specific consideration of 'silences' in the data. Collected data were analysed using cartographic approaches according to this methodology, with particular attention paid to the tenets and frameworks of patient-centred and culturally competent care.

RESULTS

Overall, content in these materials misrepresented and under-represented patients. Materials contained both outdated and unnecessarily sexualised language, in addition to a lack of patient diversity. Clinical authority was often centred over patient agency, and several updated PE techniques known to improve patient experience were absent. Patient-centred and culturally competent approaches were therefore inadequately highlighted in most of the materials.

CONCLUSIONS

Depictions contained in these materials may be perpetuating stereotypes and biases in medicine and may be working to maintain teaching practices that cause harm to patients (standardised and regular) who students interact with in both clinical and educational settings. Efforts may be needed to improve classroom materials on the PE so that they more adequately centre patients and provide opportunities to discuss culturally competent approaches to the procedure that (i) may not be covered in other parts of the PE curriculum and (ii) can reduce known health disparities.

Ensuring a successful transition from Pap to HPV-based primary cervical cancer screening in Canada by investigating the psychosocial correlates of women’s intentions: Protocol for an observational study (Preprint)

Background

Objective

Methods

Results

Conclusions

International Registered Report Identifier (IRRID)

Human Papillomavirus Infection: Knowledge, Risk Perceptions and Behaviors among SMW and AFAB

Human papillomavirus (HPV) infection is the most common sexually transmitted infection (STI) in the United States, and persistent HPV infection has been established as playing a major role in the development of cervical cancer. Providing HPV vaccination and regular screening tests have reduced the risk of developing cervical cancer or helped to detect the cancer at an early stage. Despite the above measures, cervical cancer still remains a major public health problem worldwide. Infection with HPV, and consequently cervical cancer, affects all people with an intact cervix, so not only heterosexual women, but also women from sexual minorities (SMW) together with people assigned female at birth (AFAB). These populations may be even more likely to develop cervical cancer, mainly because they are less likely to be aware of HPV transmission and prevention of cervical cancer. In our review, we summarized the current state of HPV knowledge, collected data assessing the orientation of this issue among SMW and AFAB, and indicated the causes of possible negligence in the prevention of cervical cancer.

Navigating Human Immunodeficiency Virus and Primary Care Concerns Specific to the Transgender and Gender-Nonbinary Population

Human immunodeficiency virus (HIV) prevention and treatment remain critically important to outpatient care among transgender and gender-nonbinary individuals. Epidemiologically, trans men and trans women are significantly more likely to have HIV compared with all adults of reproductive age. Here, we provide an overview of unique primary care considerations affecting transgender and gender-nonbinary individuals, including screening and treatment of HIV and other sexually transmitted infections as well as cancer screening and fertility preservation options. We also seek to review current literature and clinical practice guidelines related to drug–drug interactions between antiretroviral therapy (ART) and gender-affirming hormonal therapy (GAHT). In short, integrase strand transfer inhibitor–based therapy is not expected to have significant drug interactions with most GAHT and is preferred in most transgender individuals, including those on GAHT. Clinicians should also remain aware of current GAHT regimens and consider tailoring ART and GAHT to reduce cardiovascular and other risk factors.

Human papillomavirus self-sampling: A tool in cancer prevention and sexual health promotion

This article examines human papillomavirus (HPV) self-sampling as an approach to cervical cancer prevention and the ways self-sampling kits are promoted directly to consumers in the United States. Public health, biomedicine and health tech have increasingly imagined self-sampling, which allows individuals to collect their own vaginal specimen, mail to a laboratory for testing and receive delivered results, as a component of cervical cancer prevention and sexual health promotion. This article examines the scientific and biomedical claims used to configure the problem in need of this solution and the ways persons, publics and markets are established. We analyse scientific literature, interviews with clinicians and other key actors, and websites of directly to consumers (DTC) companies. HPV self-sampling is constructed as both a solution to inequities and gaps in cervical cancer screening and a solution to the wants and needs of those already engaged in self-projects of body monitoring and risk reduction. These multidirectional biomedical tendencies also reveal how sexuality and sexual health and cervical cancer prevention and sexual health promotion are entangled objects. While we do not want to undermine the potential of HPV self-sampling, we encourage a focus on equity and care and not commodified markets that reinforce notions of 'good' patients monitoring their health.

Southern African HIV Clinicians' Society gender-affirming healthcare guideline for South Africa

No abstract available.

Acceptability and satisfaction towards self-collection for chlamydia and gonorrhoea testing among transgender women in Tangerine Clinic, Thailand: shifting towards the new normal

Introduction

Provider‐collected swabs are an unappealing procedure for many transgender women and may have led to suboptimal rates of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) testing. Self‐collection for CT/NG testing is recommended for men who have sex with men. However, the information on acceptability and clinical performance to support a recommendation for transgender women is lacking. We aimed to determine the acceptability and satisfaction towards self‐collection for CT/NG testing among Thai transgender women.

Methods

Thai transgender women who attended Tangerine Clinic (a transgender‐led, integrated, gender‐affirming care and sexual health services clinic in Bangkok, Thailand) between May and July 2020 and had condomless sexual intercourse within the past six months were offered to collect urine and perform self‐swabs of pharyngeal, rectal, and if applicable, neovaginal compartments for pooled nucleic acid amplification testing for CT/NG infections. Participants received a diagram, video and oral instructions about how to perform self‐collection procedure. Those who accepted self‐collection were also offered to receive provider collection to evaluate the performance between the two methods. Self‐administered questionnaires were used to assess satisfaction.

Results

Among 216 transgender women enrolled, 142 (65.7%) accepted self‐collection. All who accepted had pharyngeal, rectal and urine samples collected. Of 31 transgender women who had undergone genital surgery, 28 (90.3%) accepted neovaginal self‐swab. The acceptance rate increased from 46.2% in May to 84.5% in July 2020. One participant had an invalid result. All transgender women who accepted self‐collection could perform it without assistance, and 82.8% were highly satisfied with the method. None reported dissatisfaction. Due to the COVID‐19 pandemic, provider collection services were discontinued early, and only eight transgender women were able to perform both methods for performance evaluation. The performance agreement was 100%.

Conclusions

Thai transgender women had high acceptability and satisfaction towards self‐collection for CT/NG testing. The performance was promising compared to provider collection. Our results support the implementation of self‐collection to the sexually transmitted infection services, particularly during the COVID‐19 pandemic where physical distancing is the new normal. A larger study is warranted to determine the performance of self‐collection for CT/NG testing in each anatomical compartment and confirm the performance between self‐collection and provider collection.

Concordance in HPV Detection Between Self-Collected and Health Provider-Collected Cervicovaginal Samples Using careHPV in Tanzanian Women

PURPOSE

Cervical cancer screening is one of the strategies to prevent the disease among women at risk. Human papillomavirus (HPV) DNA testing is increasingly used as the cervical cancer screening method because of its high sensitivity. Self-collection of cervical specimens has the potential to improve participation. However, there is only limited information on comparison between self-collected and provider-collected samples with regard to detection of high-risk HPV using the careHPV method. The study aimed to compare HPV detection by careHPV in self-collected and provider-collected cervical samples and to assess the acceptability of self-collection techniques.

MATERIAL AND METHODS

Women attending cervical cancer screening clinics at Ocean Road Cancer Institute, Kilimanjaro Christian Medical Centre or Mawenzi Hospital in Tanzania were included in the study. They underwent a face-to-face interview, HIV testing, and collected a self-sample using Evalyn Brush. Subsequently, they had a cervical sample taken by a health provider. Both samples were tested for high-risk HPV DNA using careHPV.

RESULTS

Overall, 464 women participated in the study. The high-risk HPV prevalence was 19.0% (95% CI, 15.6 to 22.9) in the health provider samples, but lower (13.8%; 95% CI, 10.9 to 17.3) in the self-collected samples. There was a good overall agreement 90.5% (95% CI, 87.5 to 93.0) and concordance (κ = 0.66; 95% CI, 0.56 to 0.75) between the two sets of samples. Sensitivity and specificity were 61.4% (95% CI, 50.4 to 71.6) and 97.3% (95% CI, 95.2 to 98.7), respectively, varying with age. Most women preferred self-collection (79.8%).

CONCLUSION

Overall, self-sampling seems to be a reliable alternative to health-provider collection and is acceptable to the majority of women. However, instructions on proper procedures for sample collection to the women are important.

Gender-Affirming Surgeries in Transgender and Gender Diverse Adolescent and Young Adults: A Pediatric and Adolescent Gynecology Primer

Transgender and gender diverse adolescent and young adults (AYA) may seek gender-affirming surgeries (GAS) as part of their gender affirmation. A number of GAS are related to reproductive and sexual health, and pediatric and adolescent gynecology (PAG) clinicians are well positioned as sexual and reproductive health experts to provide care in this area. PAG clinicians may encounter patients presenting for preoperative counseling (including discussions regarding fertility, family building, future sexual function, and choice of oophorectomy at time of hysterectomy), requesting referrals to GAS clinicians, or requiring GAS aftercare, or those seeking general sexual and reproductive health care who have a history of GAS. This article reviews presurgical considerations for AYA seeking GAS, types of GAS, their impact on pelvic, sexual, and reproductive health, and aftercare that may involve PAG providers, with the goal of helping PAG clinicians to better understand these procedures and to empower them to engage collaboratively with GAS teams. With this knowledge, reproductive health clinicians can have an integral role as skilled collaborators in the world of AYA GAS in partnership with GAS surgeons.

Attitudes of transgender men and non-binary people to cervical screening: a cross-sectional mixed-methods study in the UK

Background

Transgender men and non-binary people assigned female at birth (TMNB) who have not had surgery to remove the cervix are recommended to undertake cervical screening with the same frequency as cisgender women, but evidence suggests that TMNB have lower odds of lifetime and up-to-date cervical screening uptake.

Aim

To understand the attitudes towards and preferences for cervical screening among UK-based TMNB.

Design and setting

Cross-sectional survey of TMNB at an NHS gender identity clinic (GIC) and an NHS sexual health service specialising in care of transgender people.

Method

Recruitment was via email invitations to patients of the GIC and sexual health service. Inclusion criteria were: female sex assigned at birth; transgender man, masculine, or non-binary gender identity; aged ≥18 years; and UK resident. Quantitative results were analysed using descriptive statistics, and free-text comments were analysed thematically.

Results

In total there were 137 participants; 80% identified as transmasculine,18% as non-binary, and the remaining participants reported other noncisgender identities. Sixty-four participants (47%) were eligible for cervical screening and 37 (58%) of those had been screened. Only 34 (53%) of those eligible felt they had sufficient information about cervical screening. Just over half (n = 71/134, 53%) stated they would like the option to self-swab for high-risk human papillomavirus. Only half (n = 68/134, 51%) of participants were in favour of an automatic invitation for cervical screening. Thematic analysis identified a number of additional barriers to and facilitators of screening.

Conclusion

TMNB have identified numerous potential areas for change that may improve cervical screening uptake and patient experience.

Health Care for Transgender and Gender Diverse Individuals: ACOG Committee Opinion, Number 823

ABSTRACT

An estimated 150,000 youth and 1.4 million adults living in the United States identify as transgender. This Committee Opinion offers guidance on providing inclusive and affirming care as well as clinical information on hormone therapy and preventive care; it also cites existing resources for those seeking information on the care of transgender adolescents. The social and economic marginalization of transgender individuals is widespread, which leads to health care inequities and poorer health outcomes for this population. To reduce the inequities experienced by the transgender community, the provision of inclusive health care is essential. Obstetrician-gynecologists should strive to make their offices open to and inclusive for all individuals and should seek out education to address health care disparities, both in their individual practices and in the larger health care system. In order to provide the best care for patients, it is useful to know which health care professionals to include in a referral network for primary care and to have many clinician and surgeon options given the many different therapies available and the different sites at which these therapies are offered. It is important to remember that although hormone therapy is a medically necessary treatment for many transgender individuals with gender dysphoria, not all transgender patients experience gender dysphoria and not everyone desires hormone treatment. Gender-affirming hormone therapy is not effective contraception. Sexually active individuals with retained gonads who do not wish to become pregnant or cause pregnancy in others should be counseled about the possibility of pregnancy if they are having sexual activity that involves sperm and oocytes. Although being knowledgeable about the medications used for gender transition and potential risks and side effects is important, specific certification for prescribing them is not required and should not be a limiting factor in helping patients access care.

Sexually Transmitted Infections Treatment Guidelines, 2021

These guidelines for the treatment of persons who have or are at risk for sexually transmitted infections (STIs) were updated by CDC after consultation with professionals knowledgeable in the field of STIs who met in Atlanta, Georgia, June 11–14, 2019. The information in this report updates the 2015 guidelines. These guidelines discuss 1) updated recommendations for treatment of Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis; 2) addition of metronidazole to the recommended treatment regimen for pelvic inflammatory disease; 3) alternative treatment options for bacterial vaginosis; 4) management of Mycoplasma genitalium; 5) human papillomavirus vaccine recommendations and counseling messages; 6) expanded risk factors for syphilis testing among pregnant women; 7) one-time testing for hepatitis C infection; 8) evaluation of men who have sex with men after sexual assault; and 9) two-step testing for serologic diagnosis of genital herpes simplex virus. Physicians and other health care providers can use these guidelines to assist in prevention and treatment of STIs.

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.

Clinical Characteristics and Histologic Features of Hysterectomy Specimens From Transmasculine Individuals

OBJECTIVE

To describe the clinical characteristics of transmasculine individuals who underwent hysterectomy and characterize surgical pathology findings.

METHODS

Under an institutional review board-approved protocol, transmasculine individuals who were undergoing hysterectomy and bilateral salpingectomy or bilateral salpingo-oophorectomy were retrospectively identified from a single institution. Past medical, surgical, obstetric, and gynecologic history were collected, including prior testosterone use, cervical cancer screening status, and preoperative pelvic imaging. Surgical pathologic findings of the endometrium, ovaries, and cervix were collected.

RESULTS

A total of 72 individuals were included. The median age was 30 years (range 19-51). The majority of patients had private insurance (n=53, 74%) and were on testosterone at time of the preoperative visit (n=63, 88%). Forty-two patients (58%) reported anxiety, depression, or bipolar disorder, and 34 patients (47%) were taking an antidepressant or mood stabilizer. Of the 68 patients eligible for cervical cancer screening, 33 (49%) were up to date before their surgical consultation visits. Pelvic pain was the leading indication for surgery (n=65, 90%), and 29 patients (40%) had multiple listed indications for surgery. Surgical pathology results included cervical intraepithelial neoplasia 2-3 in three patients (4%), endometrial or cervical atrophy in 13 patients (18%), and ovarian or paratubal cysts in 16 patients (22%).

CONCLUSION

This study describes the distinct clinical characteristics and surgical pathology findings that health care professionals should consider when caring for this unique patient population, including a relatively high rate of mental health conditions, pelvic pain as the leading indication for surgery, and the presence of endometrial or cervical atrophy and ovarian or paratubal cysts on surgical pathology.