Maggie McKay (Host): When it comes to gynecologic care for the transgender man, there can be a lot of misconceptions. So today, we'll get the facts with Dr. Kathlyn Kim, gynecologist at Valley Health System.

Welcome to Conversations Like No Other, presented by Valley Health System in Ridgewood, New Jersey. Our podcast goes beyond broad everyday health topics to discuss very real and very specific subjects impacting men, women and children. We think you'll enjoy our fresh take. Thanks for listening.

Thank you so much for joining us today, Dr. Kim, and making the time to be here.

Kathlyn Kim, MD: Thank you for having me.

Host: So to clear up some possibly confusing areas of this topic, first of all, could you just tell us some of the terms, because I know a lot of people are not clear on what a transgender man is, for example.

Kathlyn Kim, MD: Exactly. Yes. So when we refer to transgender men, sometimes even just like locally people will just use trans, it's sort of this term to describe people whose gender identity is different than the gender that they were assigned at birth. So in today's discussion about transgender men, it is somebody born with female assigned sex at birth, but then identifies as a man. That may or may not include someone who decides to use hormone therapy or even have what we call gender-affirming surgery. So, there's sort of a broad spectrum of different types of people that we would see and take care of.

Host: Now, if you were born female, and you had the surgery, what does that entail to become a man?

Kathlyn Kim, MD: Well, again, when we talk about trans men, some of them decide to have surgery, some of them decide not to. Many of them will decide to use hormone-affirming therapy, medications to help them. But the surgery could potentially involve what they call top surgery, and that would mean like a surgery to remove the breast tissue. And sort of contour the top of them so that they would have more of a masculine contour. And then, some patients may decide to even have what they call bottom surgery, which technically in medical terms is called phalloplasty, where they may decide to even create a penis or even a scrotum, depending on, again, what they desire. So, there's a vast spectrum. Some trans men might have top surgery, but not bottom surgery. They might have both. It's not one description describes every single patient, and that's really important to know.

Host: Right. And can a transgender man get pregnant?

Kathlyn Kim, MD: Yes. Actually, they can. That's a really good question. And I know that's a very confusing question, but the answer is yes. And why that happens, or could happen, is many transgender men will be taking hormone therapy, most likely testosterone, to help them become masculine. But they will, if they haven't had, hysterectomy or other surgeries, still retain their uterus, their ovaries, their cervix. So potentially, they can get pregnant. And in fact, for some trans men patients, they decide that they want to get pregnant, that they would, you know, stop their therapy for a short period of time in order to become pregnant. So again, that is definitely a possibility. And a misconception is that because trans men are on testosterone, they feel that or they may be told that they don't have to worry about contraception, but that in fact isn't really true. So again, it's really important to specifically discuss with each patient so that they know exactly in their situation what their options are, what they need to do to make sure that they take the best care of themselves.

Host: So just to make sure I have this straight, if someone is taking testosterone, do they need to take birth control?

Kathlyn Kim, MD: They should use contraception. Yes, potentially they could get pregnant. And most trans men, they are eligible to take hormonal birth control. It's not usually something that they would want. Not that it would reverse the effects of the testosterone, but it's usually something that they're not comfortable with. So the most common form still, of course, would be having their partner use condoms if they're having penile vaginal intercourse. So, that's still very important. So yes, they still need to keep that in mind, that that's a possibility.

Host: And what kind of birth control options are available for a transgender man?

Kathlyn Kim, MD: Just like a cisgender patient, which means that they would still, you know, sort of have the same gender identity as they were assigned at birth, they could consider birth control pills, for example, or an intrauterine device, or even some of the injectable implants that we use for our cisgender patients. All of those are available. But the experience has been that that they don't feel as comfortable with it, particularly like something like an IUD, which is an intrauterine device, which is something that would have to have a procedure placed in the office, so usually it can sort of stir up uncomfortable experiences and feelings because it sort of reminds them, you know, of the uterus, et cetera. So, again, condom seems to still be very important and something that is probably the most commonly used.

Host: Dr. Kim, what sort of preventative tests do transgender men need, like Pap test, Pap smear?

Kathlyn Kim, MD: Yes, actually. So, again, if they you know, have not had a hysterectomy, what we call gender-affirming surgery, they still have female organs, they still have a cervix, they still have uterus, they have ovaries, so they need to have Pap smear screening, which is a cervical cancer test. I would still recommend that they have full STI or sexually transmitted infection disease screening and a general pelvic exam as well. So, these are very important, even though patients may feel that they don't feel comfortable or they're not sure that they even need that kind of testing, but it is absolutely important. And it's difficult because these exams might be not only uncomfortable, but also for trans men who are taking testosterone, they sometimes develop changes that might make it difficult for them to have a Pap smear or have like an inadequate sampling. So, you know, it's really important for them to know that, yes, they should come.

Host: And you mentioned UTIs, what is that and what are the symptoms?

Kathlyn Kim, MD: A UTI refers to a urinary tract infection, typically what people call like a bladder infection. So, the urethra, which is the opening to the bladder, anatomically is sort of like at the top of the vaginal opening. And during sexual activity, sometimes a little bacteria is pushed up into that area and can cause a bladder infection. Classically, people have symptoms where they feel pain, they feel pressure, they're going to the bathroom all the time. In rare cases, they can even see blood or it can travel up into the kidneys and develop into a more serious infection. But this is something that's important that is really actually really easily diagnosed and treated. But again, along with STI testing and the other routine testing, should be something that trans men should definitely be able to come in for testing for.

Host: Can you get an STI if you're not having vaginal sex?

Kathlyn Kim, MD: You can get an STI from any kind of sexual activity, although certain types of sexual activity, you're at higher risk. So if they're having oral sex, anal sex, even just genital contact without really having like penile vaginal intercourse can still allow or there's a possibility of developing any STIs, for example, HPV, which can sometimes cause genital warts, even from like intimate contact can theoretically be passed that way as well.

Host: So, if someone doesn't have symptoms of an STI, do they still need to get tested?

Kathlyn Kim, MD: Yes. Absolutely. Hopefully, people don't have symptoms. But again, routine screening is important, because you don't want to wait until those symptoms can lead to something much more serious. So, I definitely recommend that they have at the minimum annual screening and then anytime there's exposure, they're concerned, maybe there's a new partner in the picture, they should come in for additional testing.

Host: Dr. Kim, if someone has had top surgery, you were talking about that before, do they still need to have breast cancer screenings?

Kathlyn Kim, MD: That's a great question. When a trans man has top surgery, they do have breast tissue removed and sort of re-contouring, so to speak. But that is different than what we call a mastectomy, which is a cancer-reducing surgery. So theoretically, there is potentially still some tissue that remains. Certainly in a high-risk patient, you know, they would still need to have breast cancer screening.

Host: Does testosterone therapy change any risks for, say, uterine or ovarian, cervical or breast cancer?

Kathlyn Kim, MD: So, there was concerns about, since testosterone is a hormone, if, you know, there would be an increased risk. But in reviewing all of the studies, and unfortunately, there's not a long history of data, but the current thinking is that really there's been no real increased risk of uterine, ovarian or any other cancers. So, it's just the same risk that, you know, is in the baseline population.

Host: And what do you tell your patients when they ask you how they can prevent getting HIV?

Kathlyn Kim, MD: I would have this conversation with the trans man and all of my patients, they should consider always trying to use condoms if they are having any kind of penile vaginal intercourse; PrEP, which is pre exposure prophylaxis, is always available for patients. And I do think that they should be regularly tested and try to consider being sexually monogamous at one time, meaning that they should have one partner that they're exclusive with at a time so that they can minimize their exposure. You know, those I think are really good guidelines for everyone who's sexually active.

Host: Right. Earlier you mentioned HPV. What is that?

Kathlyn Kim, MD: HPV stands for human papillomavirus. It is actually the most common sexually transmitted infection in the United States. It is different than HIV and HSV, which sometimes people get confused with, because the name sounds so similar. And it's something that, as I said before, can be easily transmitted, certainly during sexual activity, oral, anal, vaginal penetration, but can even be from close contact and can cause two sort of different situations. One would be genital warts. So, warts are like a virus, like warts that people get on their hands, sort of similar to that, but they will get them in the genital area. And that's uncomfortable and, you know, upsetting to patients. But more importantly, HPV as certain high risk strains can lead to cervical cancer. So, there is a fantastic vaccine. It's called Gardasil. Now, we have the newer version, it's Gardasil 9, which protects against nine different variants and we recommend that actually for all sexually active adults, trans men as well as cisgender patients, starting as early as 9, 10, 11. And typically, it's into the mid to late 20s, but it has been now approved up to the age of 45. So, I definitely recommend that patients who haven't been vaccinated consider getting vaccination.

Host: Why so early, nine years old?

Kathlyn Kim, MD: So, we vaccinate. Vaccination is actually to allow your immune system to see something and then remember it so that it can fight it off. So, you actually want to do it before you get exposed to it. People think, "Oh no, that's a child, they're not sexually active." But your immune system, especially kids, it's so powerful and that's the best time to vaccinate. That's why we vaccinate babies, so that's the best time to do the vaccination. But still, adults are eligible, as I said, actually up until the age of 45.

Host: Wow. if someone is taking testosterone, what can they do to address pain or blood during receptive sex?

Kathlyn Kim, MD: What happens sometimes with testosterone is, there's all the good things that testosterone does for trans men, gives them the hair that they want, sort of the masculine muscle tone, libido, et cetera. One of the bad things, unfortunately, sometimes if they still have their female organs is they can develop dryness sometimes, the fancy term is called atrophic changes, and so sometimes that can cause pain and even sometimes a little bit of bleeding when they're sexually active. Typically, I recommend certainly is they use lubrication, but then there are a couple of great options. One is there's these really nice hyaluronic acid suppositories, something like a moisturizing suppository that they can use to help the tissue. And then, sometimes I'll even recommend vaginal estrogen suppositories. And while there's a concern, "Oh, I don't want to take any estrogen," but these just works locally to help the problem and does nothing to reverse any of the effects of the testosterone. It works usually pretty well.

Host: So, is it normal or common to bleed if you take testosterone?

Kathlyn Kim, MD: it certainly happens. I wouldn't say that it's common, but it certainly can happen. And it should be evaluated, by the way. You know, hopefully, a trans patient would come in and want to be evaluated just to make sure everything's okay.

Host: right. What would a typical gynecologist visit for a transgender man involved?

Kathlyn Kim, MD: Here at Valley, we're actually trying really hard to make it so that a patient would come in and, number one, feel comfortable coming into, you know, one of the offices, like typically my office. For example, the staff is prepared to greet them, our intake information tries to be mindful of the pronouns and asking sort of gender neutral questions, et cetera.

For a routine exam, just like anyone would come in, just a history, update their medications, make sure they're up to date on any screening for themselves, if they have any family history, what other complaints, they have. And then, as I said, routine Pap smear screening, STI screening, you know, urine testing if necessary, and then blood work if there was something that they had to be evaluated for.

Host: It sounds like Valley has done a lot to go out of their way to make it a welcoming environment for a transgender man to come and get, a visit. What else have they done? You mentioned making them feel at home. What else?

Kathlyn Kim, MD: So, as an institution, the entire medical group has instituted required training for all staff members. From the business associates who greet the patients, to the physicians, to the medical assistants, so that people are familiar with the terminology, just like what we talked about today. We have, as I said, signs that welcome LGBTQ+ community, trans men patients. And I think doing something like this hopefully will send the message out that this is an available option for them to come in and that we have physicians who are open to providing care and making sure that trans men feel comfortable.

Host: And that's what it's all about. Because if they don't have a place to go where they feel welcomed, as you said, or wanted, they probably might just skip doing it altogether. And that's no good.

Kathlyn Kim, MD: Exactly.

Host: Thank you so much for sharing your expertise on a sensitive topic that may not get discussed that often, but hopefully is being discussed more.

Kathlyn Kim, MD: Oh, thank you so much for having me.

Host: Absolutely. That's Dr. Kathlyn Kim and for more information about obstetrics and gynecology at Valley, please visit valleyhealth.com/obgyn or call 1-800-VALLEY1, 1-800-825-5391, to schedule an appointment. For more information on today's topic or to be connected with today's guests, please call 201-291-6090 or email valleypodcast@valleyhealth.com. If you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you. I'm Maggie McKay. Thanks for listening to Conversations Like No Other, presented by Valley Health System in Ridgewood, New Jersey.