Transgender and non-binary people

• Transgender and non-binary people are individuals whose gender identity does not align with the sex that was assigned to them at birth
• Transgender (or trans) is used as an umbrella term, recognising that people may describe themselves in many ways including the use of indigenous terms such as: whakawāhine, tangata ira tāne, tāhine (Māori), māhū (Hawai’i and Tahiti), vakasalewalewa (Fiji), palo-pa (Papua New Guinea), fa’afafine (Samoa), akava’ine (Rarotonga), fakaleiti or leiti (Tonga), or fakafifine (Niue). Western definitions or understandings of transgender do not translate in meaning to the Indigenous understandings of the above terms.  Some Indigenous trans identifying people may also use Indigenous and Western identity terms in duality depending on context and geographical locality
• Rates of sexually transmitted infections (STIs) among trans people in Aotearoa New Zealand are largely unknown due to the lack of gender identity information held against National Health Indexes (NHIs). Some information is being collected by the Institute of Environmental Science and Research (ESR) on gender identity from the case reports for the notifiable conditions of gonorrhoea and syphilis
• Risk of STIs among trans people likely increases if there are other risk factors present, e.g. drug use, sex work, sex with men who have sex with men (MSM)
• Available data suggest that world-wide, trans women are at high risk of HIV. In Aotearoa New Zealand the AIDS Epidemiology Group report annually on the numbers of new HIV diagnoses including for trans people but do not report separately for trans women
• Trans people have often experienced social stigmatisation and discrimination, including within healthcare settings, that create barriers to accessing health services. A sensitive approach acknowledging that each person is the expert on their own gender identity, and enquiring about and using preferred name and correct pronouns is essential
• Care must be taken discussing and conducting STI testing with trans patients. Many trans people experience dysphoria related to their genitals and find genital examinations very challenging
• Ask patients their preferred names for their anatomical sites (e.g. before we get started, I’m going to take a brief sexual history – do you have any language you prefer to use for your body or your genitals so that I can help you feel more comfortable?). It is important to avoid any assumptions about sexual practices and partners (e.g. do you have sex with people with a penis, people with a vagina, or both?)
• Trans people experience high rates of sexual assault and have often had negative experiences of health care, so sensitive history taking is imperative. In the 2019 Counting Ourselves survey, trans participants were 3 times more likely than cisgender women and 10 times more likely than cisgender men from the New Zealand Health Survey to report a history of sexual assault
• Use of hormone therapy does not affect STI screening, but it can affect the vaginal microbiome and the interpretability of vaginal microscopy to investigate vaginal discharge
• People who are eligible (trans people who have condomless receptive anal sex with men) should be offered HIV pre-exposure prophylaxis (PrEP). Daily dosing is recommended as the efficacy of non-daily PrEP dosing has not been evaluated for trans people. While data are limited, concerns have been raised regarding the potential effects of oestrogen on the tissue levels of tenofovir and emtricitabine. Condom use should be encouraged in addition to PrEP use
• Testosterone is not a method of contraception for people with a uterus. There are various hormonal and non-hormonal options that can be offered in this situation. Similarly, use of oestrogen by people with a penis does not guarantee contraception. See the Aotearoa New Zealand Guidelines for Gender Affirming Healthcare for more information

See sexual health check guideline also

• Transgender and non-binary people should be offered sexual health screening based on anatomy, sexual practices and patient preference
• Consider self-collection of samples for testing. Examination is recommended if symptomatic
• People with a vagina may be offered self-collected vaginal, anal and pharyngeal swabs depending on sexual practices. A first-void urine might be preferable to the patient but may be a less sensitive test
• Testosterone can cause vaginal dryness; extra lubrication and a small speculum may increase comfort if an examination is needed. Oestrogen cream applied topically to the vagina for approximately two weeks prior to a speculum examination may also be helpful
• People with a neovagina (post genital gender affirmation surgery), should be offered first-void urine testing in addition to a neovaginal swab. Colon-derived neovaginal tissue is inherently more susceptible to bacterial STIs than the penile inversion neovagina
• If examination of a person’s neovagina is needed, consider an initial digital exam using a single digit to assess the length and path of the neovagina. Using an anoscope (instead of a speculum) may facilitate visual examination
• One way to ask about screening is to say: For an STI check up, we usually offer a blood test for HIV and syphilis and testing for chlamydia and gonorrhoea. People can get chlamydia and gonorrhoea in their urine, throat, bottom and cervix. You can do your own swabs of these sites if needed. Have you had sexual contact at any of these sites?

NAAT – Nucleic acid amplification test

*Māori and Pacific people, social deprivation, history of incarceration, contact of trichomoniasis

Specimen collection guidance

Clinician collected | Self-collection

Clinical indicators for testing

• The presence of symptoms suggestive of an STI
• Sexual contact with a partner recently diagnosed with an STI
• Recent history of an STI, as a risk for re-infection
• History of receptive anal or vaginal (front hole) sex without condoms
• Consider pharyngeal swabs for sex workers or for people who have sex with men who have sex with men
• Any person requesting STI testing or contraception
• Any person presenting for HIV post-exposure prophylaxis (PEP) or PrEP

Special considerations

• Cervical screening should be offered as per Aotearoa New Zealand guidelines for people with a cervix. Self-collected human papillomavirus (HPV) testing is likely to become an option in the future, for people who are under-screened
• Symptomatic bacterial vaginosis in trans people with a vagina requires treatment, but the possibility that symptoms may be related to atrophic vaginitis secondary to testosterone therapy should be considered. Discuss the option of topical oestrogen

If test results are positive, refer to relevant STI management guideline

Even if all test results are negative, use the opportunity to:

• Educate about condom use and risk minimisation
• Consider vaccination for hepatitis A and B, if susceptible (may be free at sexual health services)
• Vaccinate for HPV if under 27 years of age (funded). Consider HPV vaccination (unfunded) if aged over 27 years and frequent partner change, or if HIV positive
• Discuss illicit drug use and harm minimisation
• Discuss and activate clinical and personal reminders for regular testing according to risk, especially if behaviours indicate the need for more frequent testing

The gender Unicorn