Original Research

Journal of General Internal Medicine

, Volume 29, Issue 5, pp 778-784

First online:

Female-to-Male Patients Have High Prevalence of Unsatisfactory Paps Compared to Non-Transgender Females: Implications for Cervical Cancer Screening

  • Sarah M. PeitzmeierAffiliated withDepartment of Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Public Health
  • , Sari L. ReisnerAffiliated withDepartment of Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Public HealthDepartment of Epidemiology, Harvard School of Public Health
  • , Padmini HarigopalAffiliated withFenway HealthHarvard Medical School
  • , Jennifer PotterAffiliated withFenway HealthHarvard Medical SchoolBeth Israel Deaconess Medical Center Email author 

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Little is known about whether and how screening for cancers of natal reproductive structures, including cervical cancer, in female-to-male (FTM) transgender individuals differs from cancer screening among non-transgender females.


To investigate anecdotal reports from clinicians of high rates of inadequate Papanicolaou (Pap) tests among transgender men.


Results of Pap tests performed on 233 FTM and 3,625 female patients at an urban community health center between 2006 and 2012 were extracted from an electronic medical record.


Compared to female patients, FTM patients were more likely to have an inadequate Pap, with prevalence of inadequate samples 8.3 times higher among tests of FTM patients (10.8 % vs. 1.3 % of tests). FTM patients had over ten times higher odds of having an inadequate Pap after adjusting for age, race, and body mass index (AOR = 10.77, 95 % CI = 6.83, 16.83). When years on testosterone therapy was added to the model, the relationship between transgender identity and Pap inadequacy was attenuated, but remained strongly associated (AOR = 6.01, 95 % CI = 3.00, 11.50), and time on testosterone was also associated (AOR = 1.19, 95 % CI 1.04, 1.36). FTM patients were more likely than females to have had multiple inadequate tests, and had longer latency to follow-up testing.


The high unsatisfactory sample prevalence among FTM patients is likely due to a combination of physical changes induced by testosterone therapy and provider/patient discomfort with the exam. Clinicians should receive training in increasing comfort for FTM patients during the exam. FTM patients should be alerted that high rates of inadequate screening may require follow-up testing. Alternatives to repeated Pap testing, such as cytologic reprocessing of inadequate samples or primary human papillomavirus (HPV) DNA screening, should be studied for efficacy and acceptability among FTM patients.


female-to-male transgender Papanicolaou test cancer screening