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



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.

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SMP had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. We would like to thank Timothy Cavanaugh, MD and Ruben Hopwood, PhD, MDiv for their suggestions on this manuscript.

Conflict of Interest

The authors declare that they do not have a conflict of interest.

Author information

Correspondence to Jennifer Potter MD.

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Peitzmeier, S.M., Reisner, S.L., Harigopal, P. et al. Female-to-Male Patients Have High Prevalence of Unsatisfactory Paps Compared to Non-Transgender Females: Implications for Cervical Cancer Screening. J GEN INTERN MED 29, 778–784 (2014).

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  • female-to-male
  • transgender
  • Papanicolaou test
  • cancer screening