Keep it relevant: Asking trans people about their bodies.

Sometimes the fact that someone is trans will be relevant to the care you give them, but at other times it won’t be. This section focuses on navigating conversations with trans people about their bodies and when it is (and isn’t) relevant to ask them about any transition related surgeries they might have had or hormone they might be taking.

It’s important to note that not all trans people will have had transition related surgery or be taking hormone replacement therapy. This can be influenced by a number of factors such as NHS waiting times, their relationship to their body, chronic illnesses and disabilities. Do not assume that a trans person does not experience dysphoria related to their body just because they present in a certain way or have not accessed certain aspects of transition-related care.

It’s important to understand that trans people might experience dysphoria associated with different parts of their body or different bodily functions. This might relate to the presence of some things and the absence of others. These might include:

  • Body hair and facial hair
  • Breasts
  • Erection and/or ejaculation
  • Genitals
  • Hair loss
  • Height, hand and foot size
  • Laryngeal prominence
  • Menstruation
  • Prostate
  • Urination
  • Uterus and ovaries
  • Voice pitch

A trans person’s dysphoria could be triggered by:

  • The language used about their body (or talking about that part of their body at all)
  • Others seeing certain parts of their body
  • Physical examination of certain body parts

As a clinician, you might need to talk to your patient about things that might make them feel dysphoric and you might have to physically examine them. If it’s clinically necessary, then it should not be avoided. However, there are steps you can take to reduce the dysphoria a trans patient might experience. These steps are good practice, whether or not your patient is trans or not:

  • Ask them what language they use to refer to their body and mirror that when talking to them. Use anatomical terminology in your notes, but also include a list of terms they use to describe those body parts – this will help your colleagues to support them in future.

  • Before a physical examination or intervention, explain why you need to do it and what you’re going to do. Ask if there’s anything you can do to make them feel more comfortable and let them know that they can ask you to stop the examination at any time.

  • If you ask them to undress, only ask them to remove the minimum amount of clothing. If it’s possible for them to remain dressed and to raise or lower the clothing slightly, then do that instead. Keep the physical examination as brief as possible and allow the patient time to put their clothing back on before you continue your conversation with them.

  • If your patient seems upset during the examination or procedure, acknowledge it rather than ignoring it. Ask them if they’d like you to continue and get it over with, or if they’d prefer you to stop. If it’s not possible to stop, let them know that you’ll be done as quickly as possible.

  • If your patient seems upset during the examination or procedure, acknowledge it rather than ignoring it. Ask them if they’d like you to continue and get it over with, or if they’d prefer you to stop. If it’s not possible to stop, let them know that you’ll be done as quickly as possible.

  • Avoid rushing the patient straight out of the consultation room after the examination or procedure. Distress can manifest in different ways and it may not necessarily be apparent that the patient is upset or experiencing dysphoria. Give them a moment to breathe before checking that they’re ok and offering them the opportunity to ask you any questions.

  • Keep the number of staff in the room to a minimum. Be aware that, whilst it might be a good learning experience, this might not be the best appointment for a student clinician to shadow in.

There are occasions where it will be relevant to ask a trans patient about aspects of medical transition that they may have accessed.

These might include:

  • When considering prescribing medication that would be contraindicated if a patient is on hormone replacement therapy.
  • When investigating hormone levels for matters unrelated to a person’s medical transition.
  • When considering prescribing medication that could make hormone replacement therapy less effective.
  • If their symptoms are consistent with a urinary, genital or gynaecological condition, pregnancy, an enlarged prostate, or certain types of cancer.
  • If you need to catheterise them. This is particularly important before catheterising trans men and non-binary people who’ve had a phalloplasty or metoidioplasty with urethral lengthening because their urethra may be narrower than other people’s or may take a less direct route to the bladder.
  • Issues with the hand or wrist, if the patient has had radial forearm phalloplasty. That will usually be apparent by the distinctive scar.

If you do need to ask a trans person about their medical transition, explain why you’re asking. Trans people are accustomed to inappropriate curiosity and questions about their body so it’s important that they understand that you are asking for a specific purpose.

Men who aren’t trans can’t get pregnant, but it’s not possible to tell if a man or masculine presenting person is trans just by looking at them. Some trans men and non-binary people can and do get pregnant. For this reason, it’s important to ask everyone if there’s a chance they could be pregnant in situations where you’re required to ask – for example, before an x-ray or prior to surgery. Explaining that it’s a question you ask every patient will reduce the risk of triggering dysphoria in trans men and non-binary people.

For treatments that could impact a person’s fertility, don’t assume that a trans person won’t be interested in fertility preservation. Being genetically related to their child(ren) is important to some trans people. However, be aware that conversations around fertility may need to be had sensitively.

When screening for, diagnosing and treating cancers of the reproductive systems, it is important to understand that your treatment of a trans person might be different than for your other patients. In these circumstances it will be important for you to understand which aspects of medical transition your patient has accessed.

Gynaecological cancers

Trans men and non-binary people assigned female at birth face a number of barriers to cervical cancer screening. Currently any trans man or non-binary person with a male sex marker on their NHS record will not be included in the call-recall system. Some GP practices and trans-specific services will actively encourage them to book an appointment, but often the onus is on the individual trans person to keep track of when they’re next due to be screened. If someone has had a hysterectomy, they are of course no longer at risk or cervical cancer.

Taking testosterone typically causes menstruation to stop and can result in vaginal atrophy, which makes bleeding after vaginal sex more common. This may be relevant when diagnosing or ruling out gynaecological cancers in trans men and non-binary people.

Some symptoms of gynaecological cancers may be masked be the effects of taking testosterone, so it will be important to consider that as part of the diagnostic process.

Prostate cancer

Trans women and non-binary people assigned female at birth retain their prostate and could therefore develop prostate cancer. If your trans patient takes oestrogen or medication to block the effects of testosterone, PSA may be lower. For this reason it’s advisable to conduct an internal examination. For patients who’ve had a vaginoplasty, the examination should take place via the vagina rather than the rectum.

Bowel cancer

Some vaginoplasty techniques use a segment of bowel to create the vagina. If a trans woman or non-binary patient has had vaginoplasty, it will be relevant to find out which technique was used for their surgery. This is because any abnormalities found in their bowel may also be present in their vagina.

Breast cancer

Anyone aged between 50 and 70 should access breast cancer screening if they have breasts. This includes trans women and non-binary people who’ve developed breasts as a result of oestrogen treatment, and trans men and non-binary people who developed breasts at puberty. As with cervical cancer screening, trans men and non-binary people with a male sex marker on their NHS record will not automatically be called for screening. Trans men and non-binary people do not need to access breast screening after top surgery UNLESS they have been told by a doctor they at increased genetic risk.

OUTpatients is the UK’s LGBTIQ+ cancer charity. You’ll find more information on trans inclusive cancer care on the OUTpatients website.

UK Cancer and Transition Service offer a service for trans people who have cancer or a history of cancer that interacts with their gender affirming care. Find out more on the UCATS website.

I had to go through like the whole process of like, two nurses, a surgeon, and the surgeons assistant, all coming in and asking you the same questions on the day of the operation. But all completely respectful. I realized at the at the end of the day, I turned to my partner, and said, if you realized no one has said the word penis from, like, the time I turned up here, to the time of discharging. And we’ve had reasons to talk about that area of the body throughout the whole day, including how to look after and maintain a catheter, all sorts of things, descriptions of what the what actually occurred in the operation, all of these things. They had just been led by my language and what I wanted to say, because I didn’t say it, they didn’t say it’s just really impressed by that.”

from Trans Inclusive Healthcare? Trans people’s experiences accessing healthcare in the UK (2024)

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