February 21, 2020
We Are Not A Monolith: Cervical Cancer Screening in the LGBTQ Population

We Are Not A Monolith: Cervical Cancer Screening in the LGBTQ Population


[Music] Pap smears save lives and we need to make sure that everyone has access to that, not just the well-off, the well-to-do, the lighter pigmented. Whether you’re facing someone who’s black or LGBTQ, we’re not a monolith, so there are different experiences. Our intersectional identity definitely informs our experience, but there can be so many different things that happened in between that and around that, so it’s not just like black-and-white of thinking, “okay, this person’s black, bisexual– okay, I know their entire identity.” No. And it’s not enough for a medical provider to say, “Oh, but I think of everyone as equal, and I think of this interaction as equal.” It’s like, well, that’s terrific, you don’t get to decide. But there is a lot that you can do to communicate to someone that you are invested in a collaborative relationship with them, and some of that stuff is small. [Music] HPV is transmitted via intimate skin-to-skin contact, so it doesn’t have to be penetrative sex, and HPV can travel in moisture, so if you’re getting HPV even on the outside, even if you’re not having penetrative sex, it can travel inside, it can travel into the vagina or the frontal canal, or it can travel rectally, and so for all those reasons it’s really important. You know, some people may not be having sex with body parts, but they may be having sex with toys and sharing toys, and so all of those things are ways that you can transmit HPV. So when you think about it that way there is such a broad range of sexual activities that can transmit this virus that there really is no one population that is not at risk, and that means that whether somebody identifies as lesbian, bisexual, or is a transgender person with a variety of different sexual activities they all need to be considered for cervical cancer screening. One of the things my PCP was extremely helpful with was saying, “you’re great about going to the gym and taking care of yourself and taking care of your parts in this way. You know, let’s think about it the same way. Let’s think about your internal health the same way that you’re thinking about the external. We want everything that’s reflected on the outside to be reflected on the inside. And if you got it, we gotta check it out.” Music The doctor herself, obviously they ask you, “are you sexually active?” And I was like, “yeah,” and she was like, “do you use condoms?” and I was like, “well, I don’t have sex with guys.” She made a face, And I think she was just kind of like–this is the older woman–she just didn’t know how to respond to this response, and it was just awkward after that. It was very uncomfortable. And then I really feel like she was just rushing and just trying to get through the thing. She didn’t talk through anything. I didn’t know what was next or what I was supposed to do. Be okay when things get awkward or sensitive or if I get upset because I might get upset. “What’s the name that you prefer that I use?” or “What pronoun would you prefer that I use?” is a good starting point in any relationship. Like that’s a question that I ask absolutely everyone even if I think I know the right answer because part of what that does is that it establishes a culture of what you are and what your needs are is inherently valuable to me, and I’m actually not going to make any assumptions, including an assumption about your pronouns. For a lot of people, especially trans folks and folks who may have complicated relationships with their bodies, like I do, it can be triggering to hear a word that can perhaps bring up a lot of feelings. “How do you want me to address what I’m evaluating, and what language would you like me to use when I’m describing what I’ve found?” My patients often are very forthcoming as to what language they’d like me to use, so we set that up right at the beginning. One, the forms: there was no way for me to identify myself outside of male/female, what my license said versus who I identify as. So it was very odd for me to come out to them, and I could tell that they had never worked with a trans person before. As a provider, if you don’t educate yourself on what is happening with transgender bodies, specifically when they’re on HRT, hormone replacement therapy, or if they’ve had medical intervention, if you don’t have information about what that looks like on a trans body, it shows. Testosterone causes changes so there’s not a lot of exfoliation or shedding of cells. So we may do a Pap, they get through the exam And then the test comes back, “Insufficient cellularity, can’t give you a diagnosis.” So they need to know about that upfront. And because of that I often will cause bleeding, so I definitely address that before they leave my office. When it comes to doing exams on someone’s body, I think it’s really important for a patient to really feel like they have control of that, and the only way to know and the only way to give a patient control is to ask questions, like, “what makes you feel comfortable?” Personally being someone with a history of trauma, having somebody do something that is such an invasive procedure and not really pay attention to my comfort and not ask me about those things as well really, just made it a pretty bad experience. As someone who’s a medical provider, you don’t actually need the content of their trauma. But if the if the conversation instead can be like, “I recognize that bodies are complicated, and I recognize that wanting to engage with and take care of bodies can sometimes be complicated for folks for lots of really good reasons, and so I’d like for you and I to be in this together, and I’d love to hear from you if there’s anything in particular that would be helpful to you for us to be in connection around this, and if you need to check out, that’s fine.” I think other things that I do is just try to explain that it might be uncomfortable, and you might feel pressure, but you shouldn’t feel intense pain. This shouldn’t be traumatic, and if it is we should stop. There are a lot of other things with regard to physical comfort. I think using lubricant makes a huge difference in how easily the speculum can be introduced. Using a small speculum is super important. Sometimes I’ll give patients speculums to bring home and some lube to bring home so that they can practice to get a sense of what it feels like. Some people listen to music. Sometimes patients want to hear, if we get to the Pap, patients want to hear exactly what’s going on and really talk about the whole thing, and other patients want to hear about nothing that’s going on, and that’s fine too. I also wonder if there’s a way to think about the actual layout and splaying of my–you know–hoo-hah. Is that the only way to check my cervix? Maybe giving people options in terms of their positioning during the procedure. Does it feel better to be lying on your side or having your feet on the table as opposed to in the footrests? Or even thinking about having you insert the speculum yourself or having a trusted person like your partner or a really close friend insert the speculum. Do you need a support person in the room? Do you need me to be chaperoned? We go through all of that before even entertaining doing the exam. Music My partner at the time had a concern about HPV. I made an emergency visit to my provider, but not my actual doctor. He says well, “You don’t have a cervix. So you’re gonna be okay.” And I said to him, “Well, I do. I do.” It’s really all about the practitioner and the understanding that they can hold the space of “Okay, yes, I’m looking at a vagina, but I’m also working with a man or I’m working with someone who’s male-identified.” Like I never ever want to have another well-woman exam in my life. I’m not a woman. I don’t need that exam. Do I need a physical? Yes. Do I need a well person exam? Yes So let’s think about what those things are called. Pap smears are one of the most invasive exams that we do in primary care and one of the most sex-specific. How can we make it about cancer screening and someone’s health, and not about a “women’s health issue,” which it’s not, right? [Music] Unfortunate Distant Terrifying Necessary Invasive Empowering Well-lubricated Awkward Uncomfortable, but it does get better

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