Transgender and nonbinary individuals have experienced discrimination and prejudice as well as interactions with healthcare professionals who were not comfortable with or educated in providing gender-affirming care. When it comes to abdominal and pelvic ultrasound in this patient population, gynecologists should be aware of the healthcare barriers and issues that transgender and nonbinary people face.
Understanding Transgender Healthcare
OBGYN clinicians play a critical role in providing competent and comfortable care to transgender and nonbinary patients. A report by the Williams Institute shows that roughly 1.4 million adults in the United States identify as transgender. But less than 40% of transgender people seek routine healthcare. Many report fear of mistreatment as the main reason they avoid seeking healthcare.
Ultrasound Imaging in Abdominal and Pelvic Health
Transgender men may experience chronic pelvic pain (CPP) in relation to testosterone administration, according to an Obstetrics & Gynecology study. The differential for evaluating CPP is broad and includes gastrointestinal, urological, gynecological, musculoskeletal, and emotional/psychiatric causes.
A physician should perform a thorough exam, and will want to take into consideration comfort and lubrication. If the patient takes testosterone and does not use their vagina for penetration, a speculum may be too uncomfortable—consider a pediatric-size speculum and evaluate for vestibulodynia first. If this is present, a topical lidocaine ointment may improve comfort.
If the exam does not show a clear etiology for the pain, imaging such as an abdominal and pelvic ultrasound should be considered.
Transgender men should also be evaluated for endometrial cancer if they have symptoms. Ultrasound is typically the imaging modality of choice to help aid when coming to a diagnosis.
Challenges in Imaging for Transgender Patients
Transgender patients may experience gender dysphoria during a transvaginal ultrasound. The Obstetrics & Gynecology study suggests that OB/GYNs consider transabdominal imaging if that can adequately visualize the uterus. If a patient requires a transvaginal ultrasound, the institution should consider offering counselling for the patient, as well as ensure the ultrasound provider is trained in competent, gender-affirming healthcare.
Masculinizing hormonal therapy with testosterone in transgender men is linked to an increase in ovarian follicular count and volume. On imaging, these changes may look like polycystic ovarian syndrome. In sexually active transgender men with uteruses and ovaries, imaging considerations may include tubo-ovarian abscess, pelvic inflammatory disease, and pregnancy, according to a study in Applied Radiology.
In transfeminine patients who elect to have vaginoplasty, the radiologist performing the imaging must be aware of how to appropriately evaluate the neovagina on CT scan or MRI for potential postoperative complications. Similarly, transmasculine patients who have phalloplasty may require evaluation with CT to assess for underlying abscesses and any urethral issues.
Best Practices for Providers
Creating a supportive, inclusive, and gender-affirming environment for transgender patients who need ultrasound imaging is critical. Many transgender patients have suffered discrimination and prejudice, and many do not seek routine healthcare because they have had or fear a negative experience.
Gender-affirming care includes asking what someone's pronouns are and then using them. It also includes using gender-neutral terms for anatomy and/or asking the patient what terms they prefer to use for their own anatomy. An awareness of any past trauma history is also important. A thorough medical history should include trauma history as well as the patient's history of gender-affirming care and treatment.
A truly gender-affirming environment goes beyond the physician and includes office staff, nurses, and sonographers. With training on inclusive practices and the barriers and needs of transgender patients, a comforting, affirming, and respectful practice can be built.
