beyond the pap: preventative care for all!

Language note: everyone uses different words for their genitals, and that is rad! In this post I am sticking with very basic anatomical words, but please feel free to change them in your head as you are reading to language that actually speaks to you and your body.

In this post, we’re gonna take on the annual exam. And even more than that, we’re gonna take on the idea of preventative care for people of all gender identities and with all different kinds of bodies. So, the question before us is:

what is preventative care and what does it have to do with me?

Usually, preventative care is talked about as “the annual exam” and is most heavily emphasized for people with female bodies. However, preventative care is much broader than that. And it’s not just about the pap smear! And it’s not just for girls!

And even if it was just about the pap smear, in the past few years changing guidelines around pap smears and pelvic exams have brought forth a lot of confusion. Raised on the idea of the “annual exam” – which has always meant breast exam, pelvic exam, and pap smear – those of us with vaginas have been thrown into confusion about what needs to happen and when. And for folks without vaginas – or who have a vagina now but didn’t grow up with one – it can be even more confusing because there is basically no helpful information out there.

Now seems like as good a time as any to attempt to decode all this nonsense, so here goes!

First Things First

Taking care of your health is a good thing. Anything you do that is healthy is preventative – whether it’s smoking one less cigarette a day or working out three times a week. Taking care of one’s health looks different for everyone. It can mean drinking lots of water, eating more healthy foods, walking around the block, jumping on a trampoline, going out dancing, running after your kids, taking fish oil, taking a warm bath when you’re stressed, keeping your asthma or diabetes well controlled, loving and respecting your body, doing genital self exams and breast/chest self exams, etc. Regular preventative care is another way of taking care of your body and your health. It’s not the only way, but it is an important one. This post will focus on this aspect of self care – regular preventative care, aka the “annual exam” or “well person visit.”

Who Needs What?

There are many different cancer and chronic disease screenings that are built into any preventative care visit. For people who have never had surgery on their chest or reproductive organs, and have never taken hormones for gender affirmation, this can seem like a pretty straight forward thing: a breast exam looks for cancer of the breast, a pap smear from the cervix looks for cancer of the cervix, etc. For those of us whose bodies are a bit more complicated, it can seem confusing. But it doesn’t need to be. The golden rule for preventative care is…

do all the basics, and then screen based on what is there

Simple enough, right? For young people the basics are vital signs, listening to the heart and lungs, feeling the thyroid, doing a belly exam, etc. These assessments check for many different types of chronic disease, including high blood pressure and heart problems. As you get older, the “basics” will expand to include screening for colon cancer and high cholesterol. But whatever the basics are for your age group, once they are taken care of screening should be based on the organs present. 

Think about your body, what is there, what isn’t. Maybe you’ve had a hysterectomy for treatment of severe endometriosis – you don’t have a uterus, but did your surgeon leave your ovaries or cervix? Maybe you are a transwoman who has developed breasts from hormone therapy and has no plans for genital surgery. Maybe you are genderqueer and have no plans for hormone therapy or surgery of any kind. Maybe you have a surgically manifested vagina or penis. Maybe you were born with ambiguous reproductive organs and had surgery done on your genitals as a baby. Whatever your story, this list can help you figure out what your provider should be screening for…

  • Breasts, born with or surgically/hormonally created – If you have breasts now or had them in the past, you should have a breast/chest exam every year, and start getting regular mammograms as you get older. Even if you had your breasts removed surgically, some breast tissue still remains in your chest and should be checked with a chest exam. The exact age for first mammogram is usually between 40 and 50, depending on your family or personal history of breast cancer. Most providers recommend that you stop getting mammograms once you turn 75. 
  • Vagina, born with – Some providers believe that the outside and inside of the vagina should be examined every year; others believe that you only need this exam if you are having symptoms like bumps, itching, burning, unusual discharge, or odor. Talk to your provider about it. Important note: a vaginal exam is not the same as a pap smear.
  • Vagina, surgically created – The outside and inside of your vagina should be examined every one to two years, after you have healed from surgery. While you are healing, be sure to get all follow up exams and see a provider if you suspect any problems. Since surgically created vaginas aren’t able to “self clean,” it is important to keep an eye out for signs of infection even long after you have healed. You won’t ever need a pap smear.
  • Uterus and ovaries – Traditionally, providers have done a “bimanual exam” every year to screen for uterine problems and ovarian cancer. This is the exam where the provider puts two fingers inside your vagina and puts their other hand on your belly – doing this, they are able to feel the size and shape of your uterus and ovaries between their two hands. There is no other screening available for ovarian cancer. While a yearly bimanual exam continues to be the recommended practice in the US, I wouldn’t be surprised if this changes soon – the fact is that, while bimanual exam is our only screening tool for ovarian cancer, it’s not a good screening tool at all. The accuracy of the exam also varies a lot with body type and individual anatomy. There are diagnostic tests your provider can order if you have symptoms of a problem with your ovaries.
  • Cervix – Finally, we get to the pap smear! The pap smear’s only purpose in life is to look for changes in the cells of the cervix. The cervix is the very bottom of the uterus, which can be seen and felt at the end of the vagina. Cervical cell changes are usually the result of HPV, a sexually transmitted infection that is super common. Cervical cell changes are not the same as cancer. Usually, an abnormal pap result tells us that very early warning signs are present. Often, the body is able to heal itself from the HPV virus and the cells go back to normal. For this reason, most people who have a cervix only need a pap smear once every three years. Research shows very strongly that doing pap smears more often than that can lead to unnecessary scares and surgeries. Also, no one under age 21 needs a pap, even if they have been sexually active for a long time. I am pretty sure that number will change to 25 at some point in the near-ish future. For now, it’s 21. You can stop getting pap smears when you are 65. 
  • Penis, born with or surgically created – There are no specific cancer screenings for the penis other than a general inspection (which involves the provider both looking at and feeling the penis). As with the vagina, some providers believe the penis should be examined every year, and others believe it should be examined only when you are having symptoms like bumps, pain, or unusual discharge. If your penis is surgically created, you should be sure to get all follow up exams while healing, and see a provider if you suspect any problems.
  • Testicles, born with or surgically created – Same story here as with the penis. If you were born with testicles you can also be checked for hernias whenever you have a genital exam. If your testicles were surgically created, you should be sure to get all follow up exams while healing, and see a provider if you suspect any problems.
  • Prostate - If you are young and have no symptoms of prostate problems, your prostate does not need to be checked on a regular basis. As you get older, an annual digital rectal exam is a good idea. For this exam, the provider inserts one gloved, lubricated finger into your butt and feels your prostrate from the inside. This usually doesn’t need to start until age 40 or 50, depending on a number of different factors. You can also have a blood test called a PSA done. For folks who are taking estrogen for gender affirmation, the PSA is not a good test because it can give false negative results – the digital exam is your best bet.

So, Wait: Should I Still Go Every Year?

Yes! If at all possible, you should! No matter who you are or what your body is like.

while not every single screening will be done every single time you go to your “annual” exam, you should go every year

Some years you will pretty much just needs the basics, and some years you will need more. But the basics are very important! In fact, your risk of high blood pressure and heart disease is much higher than your risk of cervical cancer. More people will die of these chronic diseases as well. And, spinning it another way, preventative care is an important and awesome opportunity to learn more about what health means for you and how you can be fully empowered in self care. For folks who take hormones for gender affirmation, this annual visit is also a chance to get routine blood work done to make sure you are still at the right dose and all is going well.

Bottom line: every year is the best plan, for everyone. And there are lots of resources out there to help make it possible for you to go every year.

But I Hate It!

I hear you. I feel the same way. Exams make you very vulnerable. They can be physically and emotionally uncomfortable. During the course of a preventative care visit you can have all sorts of transphobia and racism and homophobia and fatphobia slung your way, which is totally uncalled for. All these things can and sadly do happen, and they can make it very daunting and unappetizing to do the parts of taking care of your health that require a medical provider. But I promise, your annual exam does not have to be a bad experience. It can actually be a great experience. Along those lines, look for another post soon on how to choose a provider that will treat you with respect and dignity, and simple things you can do to make your exam the best experience possible.

Until then, xoxo,
Simon

 

 

 

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5 thoughts on “beyond the pap: preventative care for all!

  1. Joyful says:

    Love this post Simon!

  2. Josie says:

    quote: “Digital exam is your best bet.” —– What is digital exam?

    • boi midwive says:

      sorry for the confusion! a digital exam is when the provider inserts one gloved, lubricated finger into the patient’s butt (or vagina, if the patient has a surgically created vagina) and feels the prostrate from the inside. the other type of test for prostate cancer is a blood test, but that test isn’t great for folks who take estrogen because it can give a false negative.

  3. yes! thank you so much for this post.

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