What is the recommended approach for physically examining transgender patients?

Physical Examination of Transgender Patients

The physical examination of transgender patients must be guided by an organ inventory approach that is completely uncoupled from gender identity or appearance, combined with trauma-informed practices that prioritize explicit consent and patient control throughout the examination. 1

Pre-Examination Preparation

Establish Identity and Terminology First

• Ask the patient's current gender identity first, followed by sex assigned at birth—this two-step method emphasizes the importance of gender identity over assigned sex and increases accurate identification of transgender patients 1
• Document the patient's preferred name and pronouns separately from legal documentation, as these guide all clinical interactions 1, 2
• Ask the patient what terminology they prefer when referring to their anatomy (e.g., chest vs. breasts, genitals vs. specific anatomical terms) to reduce psychological distress 1

Obtain Complete Organ Inventory

• Document what organs are currently present regardless of the patient's gender presentation or legal sex designation 1
• Specifically inventory: presence/absence of breasts, chest tissue, uterus, cervix, ovaries, vagina, penis, testes, prostate, and any surgical modifications 1, 2
• This inventory drives what examinations are medically necessary and cannot be assumed based on appearance or hormone use 1, 2

Trauma-Informed Examination Approach

Create Safety Before Physical Contact

• Offer a chaperone of the patient's preferred gender, as this creates a safer examination environment 1, 3
• Ask explicit permission before each component of the physical examination—never assume consent 1, 2
• Allow the patient to guide physical contact and maintain control throughout the examination 1
• Explain why each examination component is medically necessary for their specific anatomy and health concerns 4

Critical Examination Considerations

• Do not require removal of gender-affirming garments (chest binders, tucking undergarments) unless absolutely necessary for the specific examination being performed 3
• Recognize that 28% of transgender patients have postponed necessary medical care and 19% have been refused care due to their gender identity, creating significant medical trauma 1
• Be aware that transgender persons experience sexual assault at higher rates than cisgender persons, requiring heightened sensitivity during genital and breast examinations 2

Examination Technique Based on Anatomy

For Patients with Cervix/Uterus/Ovaries (Regardless of Gender Identity)

• Perform pelvic examinations and cervical cancer screening based on organ presence, not gender identity 1
• A transgender man on testosterone still requires cervical pap smears if the cervix is present 1
• Testosterone therapy can cause vaginal atrophy, which may require additional lubrication and gentleness during speculum examination 3

For Patients with Prostate (Regardless of Gender Identity)

• Perform prostate examinations and order prostate-specific screening based on organ presence 1
• A transgender woman on estrogen still requires prostate cancer screening if the prostate is present 1

For Patients with Breast Tissue (Regardless of Gender Identity)

• Perform breast examinations on any patient with breast tissue, whether from natal development or hormone-induced growth 1
• A transgender woman on estrogen requires breast examination and mammography screening even if legally registered as male 1

Pain Management During Examination

Recognize Pain Disparities

• Transgender patients experience documented bias and undertreatment of pain—do not undertreate pain in this population 1, 3
• Gender identity (not sex assigned at birth) appears to play a more significant role in pain sensation, with women (both cisgender and transgender) reporting greater pain severity 1
• Provide appropriate pain control procedures, particularly for examinations involving gender dysphoria triggers 1

Address Comorbid Factors

• Screen for anxiety, depression, and substance use, which are more prevalent in transgender populations and affect pain perception 1, 3
• Recognize that affirming the patient's gender identity during examination reduces psychological distress and improves pain outcomes 1, 3

Common Pitfalls to Avoid

• Never restrict examination templates or documentation based on the patient's legal sex designation in the electronic health record 1
• Never assume surgical status or anatomy based on appearance, hormone use, or gender presentation 1, 2
• Never use the patient's legal name if it differs from their preferred name during clinical interactions 1, 2
• Never perform examinations without explaining medical necessity, as transgender patients often fear sensationalism and unwanted exams 4
• Never make assumptions about sexual practices or anatomy based on gender identity—always ask directly about organs present and sexual health history 2

Documentation Approach

• Document examinations using anatomically specific terminology uncoupled from gender (e.g., "cervical examination performed" rather than "female pelvic exam") 1
• Ensure the electronic health record allows documentation of any examination on any patient regardless of registered sex/gender 1
• Update the organ inventory after any surgical procedures to maintain accurate medical records 1