Physical Examinations

Physical examinations are sometimes a necessary and/or important part of providing healthcare to patients of all genders. However, many trans people have experienced physical examinations that are not necessary and are actively harmful. 

This page explores what physical examinations may or may not be required by trans patients and using a person-centred, trauma-informed approach to providing what can be difficult or harmful experiences. 

When are genital or chest examinations necessary?

For Gender Affirming Hormonal Therapies 

There is no need for genital or chest examinations to initiate or continue gender affirming hormonal therapy – either masculinising or feminising therapy. 

Conducting genital or chest examinations before or after initiating GAHT can constitute significant harm to trans patients, and any potential health benefit must be weighed up against the harm that may occur. 

You can find out more about how healthcare guidelines inform this approach below. 

For gender affirming surgery 

Genital or chest examinations may sometimes be necessary prior to gender affirming surgery. Any examinations should be: 

  • Performed only by the surgeon who is providing the gender affirming surgery, and not by or with any support staff, students or other health practitioners; 

  • Done only with the explicit consent of the patient, 

  • This may mean providing the patient with information about exactly how the examination will be conducted, who will be present, and the direct connection of the examination to improved health or aesthetic outcomes; 

  • Undertaken using a trauma informed approach. 

As part of support post- chest or genital surgery, it can be helpful for a General Practitioner or other healthcare provider to coordinate any follow up care or surgical aftercare. This may sometimes include the possibility of chest or genital examinations in order to support healing and recovery, and this should align with dot points two and three above. 

For other reproductive or genital related health needs 

The clinical indication for genital or chest examinations for reproductive, genital, or chest-related health needs should be assessed on a case-by-case basis, based on individual risks and preventative health care needs. 

This may include, but is not limited to: 

  • Breast/chest cancer screening; 

  • Follow up care for cervical cancer screening (CSTs) 

  • Diagnosis and/or treatment of some symptomatic STIs; 

Where possible, methods other than genital or chest examinations should be used, with examinations as a last resort for providing care.   

Using visual aids instead of examinations 

A great example of this is when ascertaining the size of a patient’s testes. To do this, you can use an aid like the wooden beads pictured, and to allow the client to self-report rather than to subject them to an examination. 

Any genital or chest examinations should be conducted using a person-centred, trauma informed approach. 

For other non-reproductive or genital related health needs 

There is no need to do genital or chest examinations, or to know the genital-surgical status of a trans patient for any other health care needs. Asking or requesting the surgical status of trans patients is a form of inappropriate curiosity and can cause lasting harm to trans patients. 

In some cases, it may be required to know the chest-surgical status of a trans patient eg. for providing care around the upper body, rib cage, for non-gender affirming surgeries, or for holistic care such as physiotherapy. 

Do the guidelines require genital or chest examinations?

No guidelines on gender affirming healthcare require genital or chest examinations. 

The WPATH Standards of Care 7 specifies: 

“All assessments should include a thorough physical exam, including weight, height, and blood pressure. The need for breast, genital, and rectal exams, which are sensitive issues for most transsexual, transgender, and gender nonconforming patients, should be based on individual risks and preventive health care needs.” 

WPATH Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People V7

It’s our and AusPATH’s interpretation of these guidelines that the standard provision of Gender Affirming Hormonal Therapies is not included in this clause. AusPATH released a statement on genital examinations that affirms this interpretation, stating: 

“The AusPATH Board of Directors wishes to make clear that [genital examination] is not in keeping with the majority view of health providers in this space.  We state emphatically that individuals have the right to decline any form of genital examination. The AusPATH Board of Directors believes that the practice of genital examinations prior to the initiation of gender affirming hormonal treatment adds little, if any, benefit to the assessment process, and creates significant trauma, embarrassment and harm to people who are subjected to this outdated practice.  AusPATH does not endorse this practice. We acknowledge that fear of being subjected to a genital examination is likely to contribute to distrust of the medical profession and harm the therapeutic relationship.” 

AusPATH statement on Genital Examinations, 29 October 2019

This additionally aligns with the Medical Board of Australia Guidelines, which state that the following are considered breaches of sexual boundaries between patients and clinicians: 

  • “conducting a physical examination which is not clinically indicated or when the patient has not consented to it. An unwarranted physical examination may constitute sexual assault or abuse”
  • “asking a patient about their sexual history or preferences, when these are not relevant to their healthcare and without explaining why it is necessary to discuss these matters”  
  • 3“asking a patient to undress more than is necessary or providing inadequate privacy screening or cover for a physical examination” 

Guidelines: Sexual boundaries in the doctor-patient relationship - Medical Board of Australia

The unnecessary examination of the genitals or chest area of trans patients can not only cause long term harm and mistrust of medical practitioners and healthcare systems but may be considered a form of sexual assault. 

How to conduct physical exams using a trauma-informed approach

If a physical exam of a patient’s genital or chest area is necessary, it is important to do so with a trauma-informed approach. AusPATH states: 

"Physicians who believe a genital examination is clinically indicated should only ever offer this as a last resort option, provided they have received the full, informed and explicit consent of their patient.” 

AusPATH

Trauma-informed care is a framework that aims to support people to feel safe, overcome their fear of harm or betrayal, and to build trust between clinicians and patients. When conducting an exam, or working with trans patients in general, trauma-informed care allows you to help mend what is often a history of poor healthcare experiences and improve the health outcomes of your client. 

Orygen, the National Centre of Excellence in Youth Mental Health, defines six core principles of person-centred, trauma-informed care which can each be specifically applied to trauma-informed examinations: 

Safety 

For many trans people, unnecessary curiosity or objectification of their bodies and/or genitals leads to feeling unsafe. The safety of your trans patients may require more work, or even compromising on ideal health outcomes. 

"Asking my patient to self-report their symptoms may have been less accurate than performing an examination, but I know that subjecting them to a genital exam would be far worse for their wellbeing than anything I’m treating them for, so it was important to prioritise that. "

Trustworthiness and transparency 

This will look like only doing a procedure once you’ve explained both every step of the process, and why you are undertaking each step. 

"When we do the examination, I’m going to ask you to remove your top and to lift your arm above your head. I’ll then ask you to direct my hand to the lump you mentioned, which will help me figure out whether you should go for a scan. It will only take around a minute, and you can say “stop” or take a break at any point. "

Collaboration and mutuality 

The nature of the doctor-patient relationship in which examinations of trans patients need to occur is that there is a power imbalance, where practitioners hold a lot of power. For trans people, this imbalance can be a reminder of disenfranchisement experienced in the world, or mistreatment from other doctors. 

Working to meaningfully share power and decision making looks like taking the time a patient needs to understand why and what will happen, and like they are an active part of the decision making process. 

"When a patient has an abnormal CST result, we like to do an examination and make sure there’s no abnormalities, but this does involve a genital examination and can be quite uncomfortable. I would like to do this follow up exam to make sure we’re catching any potential harmful HPV infection, but we don’t have to do it immediately, and I’m here to talk through how it will go and make sure you feel ready and prepared before we do anything. How does that sound? "

Empowerment 

This is similar to collaboration and mutuality, but also includes engaging, supporting, and empowering patients to advocate for their needs and care outside of your practice, such as when referring out for follow up testing or working with other health practitioners. 

"If your self-collected CST comes back positive for one of the strains that are more harmful, you’ll be referred to further testing. I've had patients say that the clinic they went to fordo follow up testing in wasn’t always affirming, and I’ll work with you to ensure that isn’t a problem and you are affirmed throughout this process. "

Voice and choice 

A key component of person-centred trauma informed care, and the health promoting principle of empowerment, is your patient being given and making choices for themselves. 

"Before we talk about your options, do you have any questions, concerns, or issues you want to discuss? I want to make sure when you leave this appointment today that there’s nothing you wished you had said or asked but didn’t feel able to. "

Culture, historical and gender issues 

This looks like responding to the wider conditions that affect trans healthcare. Most trans people report having had bad experiences in healthcare in their lives, in both gender affirming healthcare and general healthcare settings. While it is not your fault that patients have had these experiences previously, it is your responsibility to ensure that harm isn’t furthered or reenforced through your own interactions with them. 

"I’m really glad you’ve come to me to talk about your options for getting pregnant today. I want to acknowledge that the system in which I work is often not affirming and supportive of trans people’s pregnancies, but I’ll do my best to provide you with information, support, and resources despite that. My door is also always open if I mess up, and I appreciate your trust in me to come here today. "

You can read more about person-centred, trauma infomed care here.