Barriers to NHS Healthcare Faced by Transgender and Non-Binary Patients: The example of cervical screening
I am an academic foundation trainee doctor in London, with a keen interest in Obstetrics and Gynaecology, and I am passionate about the care transgender and non-binary individuals receive from obstetric and gynaecology services in the UK.
Over the past year, I have been working with a paediatrician, Dr Rebecca Trenear, who has developed trust-wide guidelines for the care of transgender and non-binary clients accessing obstetric and neonatal care services. Together we have been implementing the guidelines and have created a teaching programme for all staff. Our aim is to ensure transgender and non-binary patients can access excellent quality healthcare in a safe and secure environment, free from discrimination.
It has been incredibly eye-opening to me how underserved transgender and non-binary individuals are in all healthcare settings throughout the UK. Most allied health professionals receive little or no teaching on specific issues transgender and non-binary patients experience, and are subsequently not aware of how difficult it can be for these patients to access and use NHS services.
Furthermore, whilst many healthcare professionals aim to be inclusive, many transgender and non-binary patients report being misgendered and verbally abused whilst using healthcare services. Stonewall, a charity that advocates for improving the lives of LGBTQ+ people throughout the UK, found that 14% of LGBT people and 37% of trans people have avoided accessing healthcare services for fear of discrimination. Clearly, attitudes and practices need to change, so that transgender and non-binary clients can be assured they will be treated with respect and compassion when accessing services.
Cervical screening: an important example
Cervical screening is a key area where there are discrepancies between the care cisgender and transgender or non-binary patients receive.
The cervix is the lowest part of the womb, providing a connection between the main body of the womb and the vagina. The purpose of the cervical screening programme is to detect high-risk strains of human papillomavirus (HPV) in the cervical cells. HPV is a virus that can be spread through both skin-to-skin contact and anal, oral or vaginal sex. Certain types of HPV can cause abnormal changes to the cells of the cervix, which can eventually lead to cancer. Most people who are identified as having HPV will not go on to develop cervical cancer, but early detection allows more comprehensive follow up to be started, so that, if any changes consistent with cancer occur, treatment can be started earlier.
The national cervical screening programme is designed to screen all people with cervixes for cervical cancer every 3 years between the ages of 25 and 49, and every 5 years between the ages of 50 and 64.
Besides cisgender women, this would include transgender men and non-binary people who have not undergone a total hysterectomy to remove their cervix.
Patients whose gender is recorded as ‘female’ on their GP records are automatically invited for screening before their 25th birthday. The screening process is usually performed by a specially trained nurse, and all patients should be offered a chaperone. A speculum is inserted into the vagina, and cells are taken from the cervix using a brush. The sample is then sent to a lab to test for HPV. Patients will usually receive a copy of their results within 6 weeks, with details of any next steps required.
Difficulties faced by transgender and non-binary patients seeking cervical screening
The NHS recommends all transgender men and non-binary people with cervixes should be screened for cervical cancer as per the cervical screening programme guidelines. Despite this, transgender men and non-binary people who are registered with their GP as males will need to request regular screening appointments, as their information is not stored within the national cervical screening database. The converse is true also — transgender women who are registered as female on their GP records will be called for cervical screening, despite not requiring the service.
This presents the first issue to cervical smear testing — that the onus is put on transgender and non-binary patients to identify themselves in order to receive invites that cisgender women would receive automatically. This requires patients to be informed about the cervical screening programme, how often the screening needs to be performed, and the fact they are not automatically included in the database.
Studies have demonstrated that, whilst patients are aware of the importance of cervical cancer screening, screening reminders in the form of letters or text messages are associated with significant increases in screening rates. Not providing this service to transgender and non-binary patients is likely to reduce engagement with the programme, and potentially put them at risk of late detection of cervical cancer.
Having to directly ask for cervical screening could also cause gender dysphoria to surface. Gender dysphoria is defined by the NHS as a sense of unease a person may experience because of a mismatch between their biological sex and their gender identity. This may be more prevalent with cervical screening than other areas of healthcare, as the very nature of cervical screening may cause transgender and non-binary people to be more aware of their genitalia, which may not align with their gender identity. Automatically being referred for cervical screening may decrease some feelings of dysmorphia and anxiety, making transgender and non-binary patients more likely to attend screening.
Some transgender men and non-binary people have also reported being told by healthcare professionals they do not require cervical screening before they could explain they had a cervix and required the service. The resulting conversation could be difficult for patients to navigate, and in cases could damage the rapport between the practitioner and the patient.
Once again, teaching on transgender and non-binary issues for healthcare professionals would emphasise that it is possible for men and non-binary people to require cervical screening and that they should explain to patients that cervical screening is recommended for all patients with a cervix between 25 and 64 years of age.
Transgender and non-binary patients experiences of cervical screening
Whilst the process of cervical screening should not be painful, many patients report they find the experience uncomfortable and embarrassing. A British study demonstrated that 70–80% of eligible cisgender women underwent cervical screening, compared to 58% of eligible transgender or non-binary patients. Many transgender and non-binary patients reported they were uncomfortable having healthcare workers they did not know examining their genitalia, and others reported feeling the experience was traumatizing and caused gender dysphoria.
The NHS and Jo’s Trust websites provide advice on how to make cervical cancer screening more comfortable for all patients. They recommend trying to schedule a pre-examination appointment with the healthcare professional who is scheduled to perform the screening test, and bringing a trusted person to the appointment, who can provide support. Whilst these steps may be helpful for some individuals, unfortunately, due to COVID restrictions there are limitations on the number of face-to-face appointments which can be offered, and most clinical spaces cannot accommodate support people due to social distancing requirements.
One option which could increase screening uptake is to provide at-home cervical screening kits. These were distributed in some areas of London during the second wave of the coronavirus pandemic, where face-to-face appointments were strictly regulated.
Self-administered tests allow clients to have more control whilst the screening is occurring, and as clients can perform them in the comfort and security of their own home they have greater flexibility of when they carry out the test, who is with them and the environment they are in. Studies have demonstrated that 99% of people are able to perform a self-swab effectively, and therefore this presents a safe alternative for transgender and non-binary clients who do not want to attend in person cervical screenings.
Conclusion
Ultimately, cervical screening is opt-out, and individuals should feel empowered to opt-out if they believe the cons of the screening outweigh the pros. However, if we can ensure that transgender and non-binary clients are treated with respect and courtesy, and measures can be implemented which make the screening process less uncomfortable and less likely to induce feelings of gender dysphoria, hopefully, uptake of cervical screening among transgender men and non-binary people will increase, and subsequently, rates of cervical cancer in this population will continue to decrease.
Steps such as including transgender men and non-binary people with cervixes in the national screening database, and giving people the option of at-home testing, may also contribute to higher levels of engagement with the cervical screening programme.
It is also important to acknowledge that cervical screening is not the only area in which transgender and non-binary patients may receive poorer care compared to cisgender patients. Teaching on the role of gender, language and inclusivity in healthcare is required moving forward, to ensure healthcare professionals are providing a high standard of healthcare to all patient population groups.
Useful information
- Jo’s Trust — Cervical screening for trans men and/or non-binary people
- NHS — What is cervical screening?
- Stonewall — LGBT in Britain — Trans Report
