Pap smear....on a man?!

"Before you go and see the next patient, shut the door and let me explain something," my family practice instructor told me.

I shut the door and took a seat in his office. This wasn't unusual - many of the doctors go over a patient's history with me before I see the patient. Fortunately I haven't had any of the doctors that like to play tricks on their students, and send them into an odd clinical scenario just to see how the students react, and teach them a lesson that you should never make assumptions about your patients.

But I would never have guessed what the doctor was about to tell me.

"The next patient saw me for the first time several years ago, and throughout the initial visits confided in me that he didn't feel comfortable in his body. He was born as a woman, and has lived his whole life as a woman - including many years as an award-winning female singer- but since I started seeing him, I've been working with him to help him transition to the body of a man.

"This involved a referral to a surgeon in Ottawa who is very skilled at 'top surgery,' which involves removing the breasts, as well as initiating regular testosterone injections to change the patient's physical characteristics."

The doctor explained to me the extensive pre-injection procedures, such as counseling, and showed me the waivers and government documents that needed to be signed to certify the change in gender. The doctor also told me that for many patients, their first testosterone injection is a very emotional and memorable moment, and some even take photos or have friends present for the event.

"Despite the changes he has experienced, he still has some female characteristics," the doctor went on. "For example, there is always some breast tissue that remains after top surgery, so people who have had top surgery still need to get regular breast exams to check for breast cancer. As well, this patient hasn't had any reconstructive surgery done for the lower genitalia, so he still needs regular screening pap tests."

It took me a while for me to wrap my mind around that sentence - he still needs pap smears.

"As always, I've asked the patient if he is comfortable seeing a medical student, and he has agreed to see you. Go in and find out how the patient is doing, ask he has any medical concerns since his last visit, and then tell him he can get changed for his exam. And if you feel uncomfortable at any time, just tell the patient that this is a new experience for you. He's more than willing to help you learn."

I appreciated how friendly the patient was. I admitted my inexperience right from the start and explained that I supported his decision, and if I said anything offensive it would not be intentional. He laughed and told me it wasn't a problem.

While I talked to the patient I noticed that if I had seen him on the street, I would have assumed he was just like any other guy. He looked, sounded, dressed and acted like a man - right down to having lots of body hair and all the other changes that would be expected.

And yet, after the patient changed, the doctor performed a breast exam pap test on him, as if he was any other female patient in for her regular screening.

Despite the fact that transgendered patients have a number of unique medical needs, I have so far received little training in interacting with transgendered patients. I am sure that it won't be the last time I will have to provide care to somebody who has had a sex change, and in the future even more issues will come up, such as transgendered men being able to give birth.

After seeing the patient, the doctor explained that there was an upcoming conference for health professionals on providing care to transgendered patients. Unfortunately I wasn't able to make it because it was held during my final exams, but I look forward to the chance to being able to learn more about this in the future.