‘There Is No Manly Speculum’: The Gender and Power Dynamics of Cervical Cancer Screening for Transmasculine Patients

Abstract

Purpose: Transmasculine people are at risk of cervical cancer, yet have lower rates of cervical cancer screening than cisgender women. The cervical cancer screening encounter represents a site of complex gender and power dynamics, especially given the multiple factors that may compound the vulnerability of the gynecological exam for this population. This study aimed to elucidate mechanisms of gender and power in the gynecological encounter in order to assess how these dynamics may operate to influence patient care experiences and utilization of cervical cancer screening. Methods: A qualitative, grounded theory approach was used to analyze patient in-depth interviews (n=32), patient online surveys (n=84) and provider focus groups (n=17) that assessed experiences receiving or providing Pap tests to transmasculine individuals, respectively. Results: Interrelated factors at the institutional, interpersonal and intrapersonal levels affect the relative power the patient and provider possess upon entering the clinical encounter. The position of power each party occupies determines their level of influence over iterative processes through which gender is defined and control is exerted in the visit. Gendering processes included 1) use of patient identifiers, 2) naming of bodies, 3) invocation of gender stereotypes, and 4) representation of gender as biology. Processes that may shift locus of control included 1) consent and compliance, 2) interpersonal discrimination, 3) adherence to norms of professional language, 4) negotiation of transition-related care, 5), breaching the body, 6) objectification, and 7) othering and pathologizing. The interplay of power and gender dynamics in the gynecological encounter ultimately functions to promote or constrain patient agency over body and health. Alignment with the patient is achieved by provider affirmation of self-determined gender, whereas gender disaffirmation places the provider in opposition to the patient and asserts provider authority over patient agency. Empowering care experiences were associated with enhanced feelings of safety, capacity for self-advocacy and reduction in dysphoria-related distress whereas disempowering interactions induced feelings of violation, severe emotional distress, persistent distrust of providers and decreased utilization of care. Conclusion: The level of gender affirmation and patient empowerment during the gynecological visit has a significant impact on patient experience and subsequent utilization of cervical cancer screening. Understanding the provider role in power and gender dynamics is critical to promoting patient-centered care for transmasculine individuals. Providers can tailor behaviors and the clinical environment to modify gender defining and power exerting processes in the visit to promote patient affirmation and agency.