A Clinical Update on 2S LGBTQIA+ Affirming Care Following Implementation of Primary HPV Testing in Cervical Cancer Screening

Abstract

The 2S LGBTQIA+ (Two-Spirit, Lesbian, Gay, Bisexual, Trans, Queer and/or Questioning, Intersex, Asexual, and additional sexually and gender-diverse self-identities) population often faces barriers to care in the context of cervical cancer screening. With the shift from primary cervical cytology (Papanicolaou test) to primary human papillomavirus (HPV)-DNA testing, it is crucial to examine these populations’ healthcare needs. An intersectionality framework with an anti-oppressive lens is needed to restructure a healthcare system whose systems have traditionally erased the care needs of diverse populations through colonial, racialized, and cis-heteronormative practices. Barriers to cervical screening in 2S LGBTQIA+ populations include stigma, discrimination, limited provider guidance and understanding, and high rates of physical, sexual, and medical trauma. Self-sampling for HPV is a less invasive alternative to traditional Pap tests with a high rate of acceptability. The option to self-sample may increase participation in cervical screening based on improved privacy, comfort, and feelings of empowerment. Organizational, psychosocial, and physical recommendations for practice are shared to create a welcoming environment that reflects the diversity of populations in all aspects of healthcare. Affirmative care aims to make clients feel safe and accommodated by prioritizing dignity and respect as essential elements of eliminating cervical cancer in 2S LGBTQIA+ populations.

1. Introduction

In this paper, “2S LGBTQIA+” refers to Two-Spirit, Lesbian, Gay, Bisexual, Trans, Queer and/or Questioning, Intersex, Asexual, and the additional and evolving ways in which sexually and gender-diverse individuals may choose to self-identify [1,2,3]. In recognizing the importance of affirming care, some regional guidelines have been adapted to be more inclusive of 2S LGBTQIA+ populations to include anyone with a cervix (women, transmasculine, and non-binary people) who is/ever has been sexually active [4].

Cytology (Pap test) is a screening method that checks for abnormal cells on the cervix in order to detect precancerous or cancerous changes [5]. Human Papillomavirus (HPV) testing is a method that identifies the presence of HPV in cervical cells, which is the primary cause of cervical cancer [5]. In cervical cancer screening, there is a shift from cytology to HPV testing, which has the potential to provide options for clients to self-sample and which may increase screening in traditionally under-screened populations, including in 2S LGBTQIA+ communities [6]. While this strategy has yet to be implemented in all jurisdictions internationally, it is widely acknowledged that routine HPV-DNA testing (and informing those clients of their oncogenic HPV status) will become commonplace [6,7,8,9]. The American Cancer Society cervical cancer screening guidelines (2025) have been updated to include recommendations for self-collection HPV testing [10].

As cervical screening programs, healthcare systems, and countries prepare for this transition, it is a critical time to reflect on evidence-informed practices for 2S LGBTQIA+ populations. 2S LGBTQIA+ populations may face some barriers which are similar to other populations, such as negative attitudes or beliefs related to healthcare, medical distrust, lack of knowledge about cancer care and treatment, and limited supports, to name a few [11,12]. In addition to these barriers, 2S LGBTQIA+ populations also face their own unique challenges. While there are many strengths identified by this community, including support, interconnectedness, and advocacy [13], they also face many health inequalities. Historically, this community has faced health inequities that have been linked to discrimination, stigma, and individual health provider and organizational factors, such as providers’ limited understanding of the unique needs of various groups within the 2S LGBTQIA+ populations and strategies that demonstrate affirmative care [3]. In addition, structural dynamics such as racialization and colonialism, and social determinants of health act as barriers to broader healthcare access [3]. Healthcare inequalities experienced by this population may lead to poorer health outcomes, where 2S LGBTQIA+ populations have a higher risk of depression, anxiety, and cancer, to name a few [14]. Therefore, in the context of this transition to primary HPV-DNA testing in cervical screening programs, this narrative review focuses on affirmative cervical cancer screening by highlighting organizational, psychosocial, and physical barriers related to cervical cancer screening in the 2S LGBTQIA+ population [3]. This paper will then identify the best practices for addressing these barriers and the significance of HPV self-sampling as a harm-reduction approach to cervical cancer screening programs [15].

2. Methods

This narrative review examined existing literature on affirmative cervical cancer screening in the context of the transition to primary HPV-DNA testing, with a focus on organizational, psychosocial, and physical barriers related to cervical cancer screening in the 2S LGBTQIA+ population. We gathered evidence using several databases, including PubMed, Ovid, and Google Scholar, to gather information from clinical, critical health, public health, and social science literature, including peer-reviewed studies, policy documents, and clinical practice guidelines. The evidence included in this review focused on health service access and health equity, to inform a clinical update on 2S LGBTQIA+ affirming care in the context of primary HPV testing in cervical cancer screening. Given the limited availability of literature in this specific area, no date restrictions were applied. Furthermore, this review was guided using an intersectionality framework with an anti-oppressive lens, as described in the following section.

3. An Intersectionality Framework and Anti-Oppressive Lens

Sex, sexual orientation/identity, and gender identity/expression are relevant to all people. Identifying as 2S LGBTQIA+ is not necessarily static and may consist of more than one identity within this framework [3]. However, healthcare’s roots in colonialism have long led to the erasure and pathologization of 2S LGBTQIA+ individuals, contributing to increased barriers to 2S LGBTQIA+ health stemming from the cis-heteronormativity built into the field [16,17,18]. Similar colonial systems are found in all parts of society, impacting both social determinants of health and direct access to healthcare [3,18]. Ultimately, 2S LGBTQIA+ identity is one aspect of many that may intersect and compound the effects of existing barriers to health [19], including those concerning cervical cancer screening.

The concept of intersectionality, coined by Black feminist Kimberle Crenshaw, has created a framework to understand the compounding systems of power and privilege that act on one’s body, which uniquely positions identities, and shape lived experiences and health outcomes [19]. To promote equity and social justice, an anti-oppressive lens based on an intersectional framework is needed [3,20] to explicitly challenge the powers of oppression [3,21]. Together, an intersectionality framework and an anti-oppressive lens can support the provision of affirmative, equitable care for clients by accounting for individual contexts and experiences often erased in healthcare settings [3,17,18].

4. Barriers to Cervical Screening

The development of cervical cancer is often linked to inadequate screening [22]. The introduction of cervical screening programs has dramatically reduced the incidence and mortality rates of cervical cancer [22,23]. Systematic reviews have documented barriers to cervical screening in the general population [24], which could also be barriers to cervical screening in the 2S LGBTQIA+ populations. However, inadequate screening is disproportionately found within 2S LGBTQIA+ populations [3,25,26]. Barriers to screening for 2S LGBTQIA+ populations include social stigma, limited provider guidance and understanding, and screening nuances related to trans populations, including psychosocial and physical barriers [27,28,29,30]. For example, when healthcare professionals use heteronormative questions in clinical settings, they may reinforce feelings of apprehension if clients feel obligated to explain their sexual orientation [31]. This remains relevant as nurses and other healthcare professionals continue to make assumptions and ask their clients hetero-cisnormative questions [3,32,33]. For example, Utamsingh and colleagues found that healthcare professionals have asked about opposite-sex relationships rather than more generally about a partner [34]. Heteronormative practices and misconceptions by providers can also contribute to the underestimation of transmission and the relevance of HPV in lesbian [35] and bisexual populations [31]. Provider misconceptions of transmission for lesbian and bisexual individuals have been associated with patient disengagement from cervical screening programs [6].

A lack of foundational knowledge and the limited structures available to support affirmative care when working with 2S LGBTQIA+ populations enforce existing systems of violence within healthcare. Systemic violence, for example, deadnaming, experienced by individuals is created and maintained at social structures and institutions [36]. Deadnaming refers to the misnaming of a trans or nonbinary person using a legal name, rather than using their chosen name, regardless of intention [37,38]. Deadnaming is dehumanizing as it invalidates gender diverse persons’ identity and experiences [36], indicating a lack of respect and affirming care towards the individual and their dignity [39]. Deadnaming also carries the potential threat of creating unwanted visibility, such as when called in a waiting room [17]. Despite its gravity, the violence of deadnaming is not routinely accounted for within health systems [17] relative to the complex process of updating government or medical identification records [15]. This often-limited access to formal name changes highlights the cisnormativity of health systems as they contrast with the fluid nature of gender identity, gender expression, and sexuality for some [3,17].

Screening barriers specific to trans populations can also be related to physical and psychosocial barriers. For example, physical changes associated with androgen therapy, including the atrophy of cervical and vaginal epithelial tissue and the shrinkage of the tissues of the genital tract, can lead to uncomfortable or painful speculum insertion [27,30,40,41]. Cytomorphological changes can lead to less accurate Pap test results [30,35]. Cervical screening can also bring negative emotions relating to gender identity, contributing to client avoidance of gynecological visits [42]. These barriers highlight a need for updated provider education and cervical screening guidelines that are tailored for 2S LGBTQIA+ populations [29,30].

5. Comparing HPV and Cytology (Pap) Testing

The use of HPV testing has been recognized as the most effective screening method for cervical cancer prevention, as early detection of high-risk HPV strains allows the opportunity for closer monitoring of the development of precancerous lesions and ultimately earlier treatment [43]. HPV testing has higher sensitivity than cervical cytology, and as a result, screening intervals can be extended with little increased risk to individuals [44]. The transition to HPV-DNA screening has the potential to significantly increase the identification of those at risk of developing cervical cancer by providing a more sensitive alternative to cytology screening [6,45].

HPV testing requires a similar clinical process to the traditional cytology; however, HPV testing uses an automated, molecular test while cytology is read under the microscope and is thus more susceptible to human error [46]. Notably, testosterone therapy has not been found to impact the quality of cervical or vaginal HPV testing results with comparable accuracy between cis- and transgender individuals, unlike the impacts testosterone therapy may have on cytology results [47,48]. That is, cytology results can be unreliable in populations using testosterone therapy, while this is not a concern for HPV test reliability [41].

6. HPV Self-Sampling

For HPV self-sampling, clients self-collect their own cervical or vaginal samples [48], which is a less invasive alternative to cytology with a history of high acceptability among those who identify as women [49]. This acceptability has been consistent in systematic reviews and studies including trans and non-binary participants [48,50]. Thus, providing the option of self-sampling may increase cervical cancer screening rates in under-screened populations, including 2S LGBTQIA+ populations [40,48]. For example, it is reported that 95.6% of trans participants preferred HPV self-sampling to cytology [47], with reports of more comfort and less pain with self-sampling than with traditional cytology, citing increased privacy and the avoidance of a pelvic exam [47]. Additionally, logistical and geographical barriers are directly addressed by home-collection [40], and there is a greater ability to self-manage gender dysphoria and the pace of collection with this method [51]. Overall, being provided with the option to self-sample can support feelings of empowerment among trans participants, promoting inclinations to screen in the future [48].

Self-sampling is more cost-effective than cytology due to its association with increased participation [52]. Investment in systemic changes, such as in outreach and follow-up strategies, is needed to support this practice in 2S LGBTQIA+ populations [40,48]. For example, to combat the often-increased barriers to screening access these populations experience, community outreach members may target strategies to reach 2S LGBTQIA+ older individuals, ethnically diverse [40,48], and those living with homelessness [53]. Follow-up measures may include implementing 2S LGBTQIA+ patient navigators to help clients maneuver through health systems, and advocating for follow-up strategies tailored to these populations, when possible, as validated approaches to follow-up do not yet exist [40,48,54]. However, it is suggested that greater involvement by the screening organization in follow-up care can minimize the opportunity of ‘losing’ vulnerable individuals [54]. For example, health organizations may support the development of follow-up strategies by forming partnerships with local 2S LGBTQIA+ health organizations or community groups to integrate ongoing community insight into the needs and gaps in local programs [18]. Strategies may include facilitating screening-related interprofessional transitions of care, having clinics follow up directly with patients with positive screening results, and having the lab notify the primary care provider if follow-up samples are not received after an abnormal result [54].

7. Recommendations for Practice: Organizational Approaches

7.1. Affirming Spaces

The affirming healthcare environment for 2S LGBTQIA+ populations in the context of cervical screening means that individuals can feel safe, welcomed, and respected regardless of their sexual orientation, gender identity, and gender expression [39]. While positive 2S LGBTQIA+ representation may be important for individuals to feel welcome in this space, similarly to trauma-and-violence-informed care, this environmental culture must not require individuals to disclose their sexual orientation, gender identity, or social positioning to receive affirmative care [17]. A welcoming environment must extend beyond the representation of a diverse range of identities. Examples of representation may include decorations or reading materials that are affirmative of all gender identities and expressions and sexual orientations (e.g., brochures, posters) [25], pronouns listed on all forms of patient identification, room labels, and clinic signage [32,55]. Gender-neutral, single-stall restrooms within screening clinics may also increase safety and reduce anxiety for gender-expansive individuals, as these reduce the opportunity for their identity to be overtly challenged [56]. These recommendations can be helpful; however, further research is required to examine and identify specific changes that can be made to create affirming spaces in the context of cervical screening for the 2S LGBTQIA+ population.

7.2. Inclusion of Chosen Family

Due to the importance of chosen family in the 2S LGBTQIA+ community, policy should reflect the diverse connections clients may have to the individuals joining them to their cervical screening appointments, or who are otherwise involved in their care [57]. It is important to accommodate and legitimize the non-traditional structure of chosen family systems, as their involvement and acceptance can help improve patient care [57]. All clinical staff, including reception and administration, should receive 2S LGBTQIA+ inclusive training, specifically surrounding the use of inclusive and gender-neutral language to provide sensitive, gender-affirming care for patients undergoing cervical screening and their chosen family [32,51,58]. This training should emphasize not making assumptions about gender, pronouns, or their relation to those accompanying them, or who are listed as contacts in their charts [33,57].

7.3. Systemic Approaches

It is important to assess whether automated health promotion is reaching its intended demographic to include all those with a cervix, regardless of gender identity and expression, and to adjust outreach accordingly [30]. For example, cervical cancer screening programs may identify individuals based on sex at birth data, which may be challenging for health promotion outreach strategies targeting the broader population [15]. To address this gap, cervical cancer screening programs may consider population-specific approaches to trans healthcare needs to understand and continuously address the unique health barriers faced by this underserved demographic [59]. This may include an opt-in option for health promotion and preventative care to expand the reach of screening beyond individuals traditionally registered with providers [30].

Similar to the World Health Organization’s national approach to HPV screening programs [9], broader approaches to policy may support the creation of equitable, population-specific frameworks to address 2S LGBTQIA+ health barriers [59]. When possible, consistent, accurate documentation of 2S LGBTQIA+ patient demographics may support health promotion by facilitating research through the identification of health disparities, incidence, and risk factors in these populations [59,60]. To support this, providers should also be trained to explicitly emphasize and reinforce confidentiality and privacy in all communications when collecting client information on sexual and gender diversity [61,62]. This also pertains to communication in health forms as affirming language can increase client comfort and promote disclosure [61,62]. However, given the relatively low identification of 2S LGBTQIA+ populations, it is important to continue to provide care that is affirming for all identities and orientations without necessitating self-identification to receive affirmative care [28,41]. This care includes practitioners being explicit and comprehensive regarding their explanations of how HPV can be transmitted and who should be screened for it. For example, the Ontario Cervical Screening Program specifies that “anyone with a cervix (women, transmasculine and non-binary people)” and those in same-sex relationships who have ever been sexually active should be screened [15].

It is critical to be more inclusive in defining sexual activity. Definitions should be gender-neutral and inclusive when used in evidence-based recommendations. Inclusive definitions may help clarify long-standing misconceptions about HPV transmission in 2S LGBTQIA+, especially among lesbian and trans populations [31,35,51].

8. Recommendations for Practice: Psychosocial Approaches

Clinically, psychosocial barriers can be addressed through social and environmental considerations. Dignity and respect should be prioritized in communication with the patients undergoing cervical cancer screening [27]. Healthcare providers may introduce themselves using their pronouns, ask, document, and use clients’ pronouns to promote a culture of affirmative care [55]. For example, Dr. Smith may introduce herself by saying, “Hello, my name is Dr. Smith, and I use she/her pronouns. May I ask what name you go by and what pronouns you use?” Being specific about asking patients their gender, the name they go by, and their pronouns promotes gender-affirming care and can promote increased uptake in cervical cancer screening [63]. Using the specific terminology of asking someone their “chosen name” or the name they “go by” rather than what they “prefer” may be more validating of the concreteness of identity rather than minimizing the significance of their name to that of a preference [3,64]. Some patients may go by their name in place of pronouns, as is traditional in Indigenous language or among Two-Spirit individuals [3]. Further, while Two-Spirit is a culturally specific gender and sexual identity, not all 2S LGBTQIA+ Indigenous individuals may identify with this term, as is acknowledged by the term “Indigiqueer,” for example [64,65].

Healthcare providers may use inclusive, gender-neutral language until learning enough about the client and how they identify their body and gender to be able to mirror this language [55,63]. Some of these more neutral terms may include “pelvic exam” rather than vaginal or cervical exam, or “genital opening” rather than vagina [56]. Using clients’ indicated terminology promotes gender-affirming care and is associated with better health outcomes and quality of life for clients [66,67]. Therefore, it may be helpful to directly ask clients what terminology they use for their body parts being examined, as this will vary for individuals [39,55]. There are times when avoiding gendered terms or topics may not be possible. This could be related to systemic limitations, such as outdated forms that do not create space for gender-expansive self-identification or the possibility that certain topics may inherently be associated with gender dysphoria for certain clients, such as gynecology as a whole, or menstruation, for example [3]. When it is not possible to avoid using gendered terms or discussing these topics, acknowledging that the language or setting may not be gender-affirming can provide validation [55].

It is important to use a trauma-and-violence-informed approach when working with 2S LGBTQIA+ populations undergoing cervical cancer screening, and especially when working with transgender, non-binary, and intersex individuals, due to high rates of physical, sexual, and medical trauma within these groups [55,58,68]. While there is limited research focusing on intersex individuals’ perspectives on healthcare practices, existing literature questions the socio-culturally binary-driven pathologization of intersex bodies and non-consensual genital surgeries at birth, which demonstrates the value of erasing intersex variance over individuals’ bodily and medical autonomy [66,68]. Limited research further translates to limited medical knowledge and training related to caring for intersex clients, contributing to inequitable care for these populations, which often leads to the burden of client advocacy and educating providers disproportionately on patients [68]. For intersex, transgender, and nonbinary individuals, medical trauma may also be compounded by the potential for gender dysphoria associated with pelvic exams for these individuals or the well-founded fear of providers using these exams as novel “teaching moments” for themselves and colleagues over prioritizing client dignity and respect [55,58,68]. As follows, providers may encourage individuals to bring a support person with them, whether this be a friend, a member of their chosen family, or another member of the interprofessional team they feel comfortable with [55,57]. If it is preferable, clients may be offered the first or last appointment of the day to minimize discomfort associated with waiting alongside predominantly cisgender women, for example, if this is the clinic’s main demographic [56]. To promote inclusivity, it may be helpful to consistently use a two-step approach to assessing sex assigned at birth and gender identity when this information is needed [30].

When working with gender-expansive populations, it is also important to recognize the violence and the potential for psychological harm associated with the use of deadnames [30,39]. Practitioners can be more sensitive to avoiding their use by asking individuals what name they go by and ensuring to use these [17,39]. If it is medically necessary to confirm a deadname, practitioners might consider depersonalizing the name by using the wording of “the” legal name rather than “their” legal name [69]. If a healthcare provider accidentally deadnames or misgenders a client, it is important to quickly acknowledge, apologize, and thank the person for correcting them, and move forward to not displace the social responsibility onto the client to console the provider [55,64]. Previously, it was suggested to “apologize”, but the act of only apologizing requires the impacted person to console the healthcare provider by responding with a comment such as “It is okay” or “No problem”. If deadnaming or misgendering happens due to confusion with existing charts or identification records, and it is not possible to update the system, it may be helpful to make a note of this, along with pronouns, in the client’s chart to avoid other providers repeating the mistake [56].

To promote patient-centered, affirmative care, it is important to avoid asking questions related to gender or identity that are not medically necessary, or that are out of curiosity rather than to improve the healthcare experience during cervical screening [17,39,55]. It is also important to only examine relevant anatomy, as the purpose of cervical cancer screening is not meant to educate the provider [17,55].

9. Recommendations for Practice: Physical Considerations

Despite moving to HPV testing, considerations for affirmative care will still be needed for individuals receiving cytology. For example, clinicians can help minimize the impact of physical barriers to cytology associated with testosterone therapy by considering prescribing short-term topical estrogens before screening [27]. If there is clear atrophy of the lower genital tract (vagina), estradiol or estriol may be prescribed for one to two months before a cytology in the form of tablets, cream, or gel [30]. Providing patients with a speculum to practice with at home may also minimize the anxiety and discomfort of future visits [51].

Further considerations for cytology include providing patient education regarding the increased risk of test results being inadequate for those on testosterone therapy [70]. To minimize this barrier, providers may inform clients of this [27] and encourage the collection of a baseline cytology test before beginning testosterone therapy [70]. When adjusting for hormone-related atrophy, swabbing a greater area around the cervix than usual while being flexible in the type of instruments used for collection may also support adequate sampling [56]. Overall, patience and accommodation from providers are essential in supporting clients who may be experiencing increased pain, anxiety, or gender dysphoria related to screening [17,51].

At the time of the cervical screening procedure, further considerations should be made for discomfort related to atrophy of the lower genital tract (vagina) [27]. Providers may consider the use of a topical analgesic, such as lidocaine, at the vaginal introitus before the procedure, and the use of a pediatric, or the smallest possible, speculum [30,56]. The use of lubricants may improve comfort for all patients and may increase the adequacy of Pap results in transgender patients undergoing testosterone therapy [70]. The only contraindicated lubricants are those containing carbomers, as they may interfere with cytology results [70]. Providing the client with the option to self-insert the speculum can promote comfort and autonomy [56]. A more contextual consideration may be the use of sedatives or anxiolytics during the procedure, as these may be associated with increased trauma for some [56]. Ultimately, an HPV swab of the lower genital tract (vagina) may be considered if speculum insertion for cytology is not possible [56].

10. Conclusions

This paper discusses the ways in which explicit attention is needed to address barriers to cervical cancer screening in 2S LGBTQIA+ populations following the international shift from cytology to HPV-DNA testing. An overview of the overall recommendations for practice is summarized in

Table 1. Overview of recommendations for practice.

(1) Organizational Approaches	Create a diverse, welcoming space visually representative of 2S LGBTQIA+ populations across other forms of difference, such as race and ability [18,55]. Examples may include decorations or reading materials, pronouns listed on all forms of patient identification, room labels, and clinic signage [32,55].
	Ensure availability and accessibility of gender-neutral, single-stall restrooms [56].
	All clinical and administrative staff should receive 2S LGBTQIA+ inclusive training specifically regarding the use of inclusive and gender-neutral language [32,51,56,58], emphasizing not making assumptions about persons’ gender, pronouns [55], or their relation to those accompanying them [3,57].
	Verify health promotion material and cervical screening reminders are reaching all individuals with a cervix, regardless of gender identity [30]. This may not be automatic depending on the sex/gender recorded in electronic health records [15].
	Consistent, accurate documentation of 2S LGBTQIA+ patient demographics can promote health research [59,60].
	Healthcare providers should be trained to explicitly emphasize and reinforce confidentiality and privacy in verbal and written communications with clients when collecting information on sexual and gender diversity [61,62]. Any related forms should include similar language [61,62].
	Given the relatively low identification of 2S LGBTQIA+ populations, provide care that is sensitive to those who have chosen not to disclose their gender identity or sexual orientation [28,41].
	Practitioners should be explicit and comprehensive regarding their explanations of how HPV can be transmitted and who should be screened for it [31,35,51].
(2) Psychosocial Approaches	Prioritize dignity and respect in all verbal and written communications [27], understanding that the only way to know someone’s pronouns or gender is to ask [51,56,58]. Providers may also introduce themselves using their pronouns to promote a culture of inclusive care [55].
	Being specific about asking patients’ chosen name (rather than “preferred” name), gender, and pronouns; keeping in mind not everyone uses pronouns and may use their name in place of these, for example [3,64].
	Recognize the significance of deadnames and the potential for psychological harm associated with their use [30,39]. If it is medically necessary to confirm a deadname, practitioners might consider depersonalizing the name by using the wording of “the” legal name rather than “their” legal name [69].
	Quickly acknowledge, apologize, and thank them, and move forward from mistakes such as accidentally misgendering or deadnaming a patient [55,64]. Update the patient chart to avoid repetition [56].
	Use inclusive, gender-neutral language (e.g., “pelvic exam” or “genital opening”) until able to mirror patient language [56]. Directly ask clients what terminology they use for body parts being examined, as this will vary [56]. Only examine relevant anatomy and do not ask questions related to gender or identity that are not medically necessary [55].
	When it is not possible to avoid using gendered terms, acknowledging that the setting may not be gender-affirming can be validating [55].
	Encourage individuals to bring a support person to their appointment, specifying this may be anyone they feel comfortable with [55,57]. Keep an open mind to the patients’ relation to those who may join them [55,57].
(3a) Physical Considerations	The use of lubricants may improve the adequacy of cervical cytology results in transgender patients and increase comfort for all patients receiving a pelvic exam or cervical screening [70].
	Provide the client with the option to self-insert the speculum [56].
	Sedatives or anxiolytics may be considered with caution [56].
	Sending patients home with a speculum to practice with may minimize anxiety and discomfort [51].
	An HPV swab of the lower genital tract (vagina) may be considered if speculum insertion is not possible [56].
(3b) Physical Considerations Specific to Testosterone Therapy	Encourage collection of a baseline cytology before beginning hormone therapy [70].
	Providing patient education regarding the increased risk of inadequate test results following the initiation of hormone therapy [27].
	To collect an adequate sample with atrophy, consider swabbing a greater area around the cervix than usual while being flexible in using various types of instruments for collection [56].
	If there is clear cervical atrophy, estradiol or estriol may be prescribed for one to two months before a cytology in the form of tablets, cream, or gel [27,30].
	Topical analgesic at the vaginal introitus before the procedure and the use of a pediatric or the smallest possible speculum may reduce discomfort related to atrophy of the genital tract at the time of the procedure [30,56].

An overview of recommended clinical guidelines which may be considered when creating a space welcoming of 2S LGBTQIA+ individuals, including (1) organizational approaches, (2) psychosocial approaches, (3a) physical considerations, and (3b) physical considerations specific to testosterone therapy.

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