Culture & Conversation LGBTQ

My First Pap Smear as an Openly Nonbinary Person Was Wildly Disorienting

S.E. Fleenor

Here's how medical professionals can do better.

I didn’t want to get a Pap smear.

I’d imagine lots of people feel the same way. For me, though, it wasn’t just the discomfort of the speculum I was dreading during the routine cervical cancer screening, but also the misgendering and awkward questions I feared would follow.

Since my last exam three years earlier, I had come to terms with my gender identity. By and large, that experience had been liberating, filled with realizations that what I knew to be true of myself and my body had a name: nonbinary. Finding a term that fit felt like wrapping myself with a warm blanket. Over a few short years, I’d learned to accept myself (for the most part), to take up space, to correct pronouns, and to challenge the gender binary whenever it felt necessary—except when it came to my health.

I avoided seeking preventive care because I didn’t want to have to go through the process of explaining who I was to someone who might be hostile, or might ask questions I couldn’t answer. (I’m not an expert on being nonbinary. I just am nonbinary.) Even worse, I worried I might be refused treatment due to religious or moral beliefs, something the Trump administration recently made even easier for health professionals. Nonbinary people experience a variety of discrimination in health settings—including being expected to educate the person with several degrees sitting across from them in a suit and a lab coat while they sit on an exam table, derrière hanging out the back of their medical gown.

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After more than a little dragging of my feet, I made an appointment and showed up, hoping for the best. The second I checked in, I could tell it was going to be rough. The receptionist handed me a form to complete—with no option to note my gender—and I overheard someone say that “she” was here. I cringed and wished I could fold into myself until I became a black hole. I didn’t just want to disappear: I wanted to suck the whole building in with me.

As I waited for the nurse to call my name, I rehearsed things to say, but when she introduced me to the nursing student working with her, I froze. I had been prepared to tell one person my truth, but two was too many. We rushed through the standard questions before, I waited for the nurse practitioner. I wiped the stress-sweat from my brow, anxious to see who would be analyzing my body and my health.

Luckily, I liked my nurse practitioner. She was kind and handled a lot of things well. She asked about my sex life, whether or not I felt safe, and my sexual partners—and when I answered with perhaps atypical answers (I’m also bisexual), she marked the answers down without judgment. She also explained what the exam entailed.

“This is the speculum,” she said as she held up the vaguely familiar metal object. “It’s going to feel like a lot of pressure as the speculum opens your vagina, then it will probably cramp when I scrape your cervix.”

I cringed—not just at the idea of being pressed open by a metallic device or having my most inner innards scraped, but at the words chosen to describe my body. No one had used the word vagina in reference to my body in years. And, cervix? Yikes. That term felt so clinical I didn’t feel human, but rather a cadaver being dissected. All the work I’d done in therapy exploring my gender felt like it dissipated and instead of being the complex, beautiful, layered human who is body, identity, gender, sexuality, and more, I became a checkmark. I was no longer me, but rather a W, a pink gown, a reproductive system.

From the first awkward interaction to the nurse practitioner notifying me that I was bleeding from the scrape took about 20 minutes. And, in that time, my nurse practitioner did a lot of things right. But she and the entire staff at my clinic also missed the mark on being affirming and inclusive.

It’s not entirely their fault, though. Few providers are educated on how to treat nonbinary patients, though the National LGBT Health Education Center has released a study called “Providing Affirmative Care for People with Non-Binary Gender Identities,” that can be very helpful. Tips include making sure there is an all gender bathroom available onsite, avoiding gender specific language as a staff, and knowing where to refer nonbinary patients for more inclusive and knowledgeable care (such as a center or clinic that specializes in gender and sexuality).

Additionally, I’ve outlined some ways medical professionals can make the care they provide more accessible and inclusive to nonbinary patients:

  • Ask for your patient’s pronouns. Some clinics have made this a standard procedure on intake forms, but even if yours doesn’t, take the time to ask someone how they’d like to be referred to, including their preferred name and their pronouns.
  • Identify the terminology your patient is comfortable with. Nonbinary folks are prone to experiencing gender dysphoria, which means the clinical terms medical professionals are trained to use don’t always match the terms we’ve come to use for our bodies. This is another piece of information that can be captured on a form or in conversation with your patient.
  • Recognize overlapping identities. No group of people is homogenous. My experience as a fat nonbinary person means that I experience compounding forms of discrimination when receiving health care. We also know that Black people with uteruses experience deadly and intersectional forms of health-related racism. And, given the high rates of sexual assault and hate-based attacks LGBTQ people survive, a trauma-informed approach is always advisable. Accept the full person who walks into your clinic and be prepared to treat them with dignity and respect, regardless of your preconceived notions.
  • Apologize when you make a mistake. It’s pretty common to misgender someone when you’re new to understanding gender identity. We live in a society deeply invested in the gender binary, and you are just one person. Be gracious with yourself and apologize to the person you’ve hurt. (Yes, misgendering always hurts.) Then move on. Don’t obsess over what you’ve done wrong, just do better next time.
  • Make a plan to learn more about gender identity and health. If you’d like to make the world and your clinic a safer place for nonbinary folks, educate yourself. Read books written by nonbinary authors, sign up for a pronouns workshop at your local LGBTQ center, read the National LGBT Health Education Center’s publications, and follow nonbinary people on social media. The more you open your world to the experiences of nonbinary folks, the more you will become aware of your binary-thinking and bias.
  • Trying is enough (for now). Just making the effort goes a long way, so don’t give up. Be prepared to try, mess up, apologize, and try again. You don’t have to be perfect and you don’t have to “get it,” but it is your job to honor the realities of your patients.

The stakes are high around health care because we know that both immediate and preventive care extends and improves one’s life. When nonbinary patients delay or omit seeing medical professionals out of fear that who they are will not be accepted, it can have long-reaching impacts.

I felt that reticence myself when I was steeling myself for my Pap smear. I stood at the threshold of my doorway, keys in hand, trying to convince myself that no matter what discrimination I faced, preventing possible cervical cancer would be worth it. It was an impossible decision: Do I expose myself to harmful and painful experiences now, or do I prevent something obscure to me at this time in my life?

I need to continue to receive medical care. And despite my hesitations and frustrations, I plan on going to my next Pap smear, and the one after that, and the one after that, and so on. Right now, though, I grit my teeth as I think about it, wondering how bad it will be next time. And the reality is that that hesitation—that gut feeling of fear—is enough to keep many nonbinary folks from seeking the medical care we both need and deserve.

Sadly, my experience is mild in comparison to many of the experiences of trans and nonbinary folks seeking health care; stories of overt discrimination, including EMTs and doctors outright refusing to assist trans and nonbinary patients in emergency, life-or-death situations, are more prevalent than most realize.

For people who ascribe to the gender binary, this can all seem like a lot of work. I invite you to sit with that feeling, question where it comes from, and realize that we don’t need you to understand us to respect us and to make our health-care experiences equitable, inclusive, and without harm.

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