Gender-affirming approach to physical exams

Transgender, Two-Spirit, and non-binary (TTNB) people access healthcare for a wide range of needs, including routine screenings, acute care, preventive services, and gender-affirming treatments. Many TTNB people report avoiding or delaying physical exams due to past experiences, including misgendering, invasive questioning, inappropriate procedures, and a lack of provider knowledge about gender diversity. These experiences can lead to missed screenings, delayed diagnoses and mistrust of healthcare systems (1,2).

Physical examinations have the potential to bring up past trauma, dysphoria or distress (2). Understanding this history helps clinicians avoid replicating harm and create care experiences that are safer, more respectful and collaborative.

For many TTNB clients, physical exams are not just routine procedures, they are moments of vulnerability that are shaped by personal experiences and the history of trans health care. It is important for clinicians to acknowledge that stories told by TTNB peers, elders and community members also shape the expectations and experiences of physical exams (3,4).

Poorly conducted physical exams may contribute to mistrust, and cause delay and avoidance of  healthcare (1,4).

Healthcare practices that contribute to historical and personal harms

There are many ways that healthcare interactions and physical exams can contribute to harm. These include: 

Unnecessary or inappropriate exams:

Inappropriate questions or assumptions:

Lack of consideration:

Impact of harmful healthcare practices

Unnecessary or inappropriate questions or exams, assumptions and lack of consideration can cause distress and lasting health implications for clients. These include increased dysphoria or incongruence during exams, increased discomfort due to anxiety and increased muscle tension, and dissociation or emotional detachment as a coping mechanism

Harmful healthcare practices can cause clients to delay routine care appointments and screenings due to fear of judgement, dysphoria or incongruence, misnaming, and misgendering. Clients may postpone care until symptoms worsen and become urgent, delaying timely medical intervention and leading to poorer outcomes (4). Negative healthcare experiences and clinical environments that are perceived as unsafe may make clients reluctant to discuss or disclose personal information, leading to incomplete medical histories that could affect clinical decision-making (1,4).

To provide care spaces that are safer for Indigenous TTNB people, we must first recognize the long-standing and ongoing Indigenous-specific racism within political and healthcare institutions that continues to perpetuate and reinforce disconnection from community, language and culture.

It is essential to recognize that the ongoing harms of colonization exist alongside Indigenous strength and resilience. Indigenous communities are rich in knowledge, language and culture. Showing up authentically in caring relationships and honoring Indigenous ways of knowing will contribute to culturally safer care for Indigenous TTNB people.

Today and every day, we celebrate and honour the histories, resilience, and brilliance of Indigenous TTNB people, their families, and communities.

Using a gender-affirming relational practice approach allows exams to be more than clinical encounters: they can be opportunities to build trust and protect dignity.

Clinicians can foster trust, support gender embodiment goals, and contribute to positive care experiences by integrating the principles of gender-affirming relational practice into their care.

Gender embodiment

Gender embodiment describes the process of expressing how one feels and understands one's gender. It offers an alternative to the linear idea of "transition," recognizing that each person's journey to understand and express one's true self is unique and can take many different paths (5). 

Gender embodiment care refers to psychosocial, medical, and surgical care that supports an individual to express their true self.

For more information on a gender-affirming approach to care, see Trans Care BC’s Gender-Affirming Relational Practice Course. 

Trauma- and violence-informed care

A trauma- and violence-informed approach helps build trust, fosters therapeutic relationships, and ensures that care is provided in a way that prioritizes client safety, autonomy and dignity (2,6,7).

Choice, collaboration and connection

Safety and trustworthiness

Strengths-based and skill-building

An anatomic inventory is a record of which organs or body structures are present, absent or surgically modified. A hormone inventory is a record of whether a client is using hormone therapy (e.g., testosterone, estrogen), including type, route, dose and duration (8). These inventories guide appropriate screening, diagnosis, lab interpretation and care planning, allowing clinicians to ensure assessments and interventions are relevant and sensitive to the client’s experience (8).

Anatomic and hormone inventories allow clinicians to provide care informed by a client's physiology rather than making assumptions due to gender markers or appearance. These assumptions can lead to confusion, mistakes or missed information in care (9).

Conducting an anatomic and hormone inventory 

Tables adapted from Clark et al. (8)

Documenting anatomic and hormone inventories

Using a shared decision-making approach to physical exams helps respect individual preferences and uphold bodily autonomy. These conversations consider each client's context and outline different approaches for exams, including their risks and benefits, and possible outcomes.

When working with TTNB clients, shared decision making:

The shared decision-making model for physical examination conversations, adapted from Elwyn et al. (10), aims to support clients in moving from initial to informed preferences.

Choice talk 

Choice talk introduces the conversation and explains why this conversation matters at this moment. Choice talk should acknowledge that physical exams can be challenging, especially for those who have experienced previous trauma or who experience dysphoria related to specific body parts. At the end of a choice talk, check in to see if clients are comfortable proceeding with an examination conversation now or at a future appointment.

Option talk 

Option talk considers available approaches to physical exams based on the client's presentation and anatomic and hormone inventory. It provides clear rationales for why a specific exam, screening, or procedure is recommended. Option talk should include possible outcomes, related follow-up and explain what is involved in each part of the exam. Exam options are framed and considered within a client's context, including previous healthcare experiences, current experience of gender dysphoria or incongruence, support needs and anatomic and hormone inventory.

Decision talk 

Decision talk encourages clients to choose the examination approach that is the best fit for them. After discussing options, offering decision-support tools, and providing time for deliberation, check if the client is ready to decide. If the client remains undecided after reviewing all their options, defer the examination until a future date.

The following questions can be used to initiate discussions about physical examinations and understand client preferences and concerns.

Initiate a conversation

• Have you thought about your comfort level with physical exams?

• What questions do you have about the exam I'm recommending?

• Would you like me to review what the examination involves?

Explore examination priorities

• What is important to you when you consider having a physical exam?

• What do you value in healthcare interactions? How might this affect your examination preferences

Consider the context

• Who would you like to be involved in or present during your examination?

• What factors will impact your comfort during the examination?

• Have you heard stories from others that may impact your feelings about examinations?

• Are there any external factors that may impact your examination experience? Consider work, school, or community factors.

Indigenous and cultural considerations

• Are there any cultural and traditional practices that would be helpful for you?

• Would you like an Elder or trusted loved one to be part of this visit or future visits?

Integrate examination history

• If you have had examinations before, what was this experience like? In an ideal world, would you like to have the same experience or a different one?

• Are there factors that made examinations easy or difficult for you?

Tailored information and support

• What do you want to know more about when it comes to physical examinations?

• How can I support you in feeling comfortable during examinations?

Physical exams are inherently vulnerable, especially for individuals who have experienced previous healthcare trauma or experience gender dysphoria Distress resulting from a difference between a person’s gender and their sex assigned at birth, associated gender role, and/or primary and secondary sex characteristics. (Source: WPATH) or incongruence (2). Providing clear communication and non-judgmental support before, during and after physical exams can create safer healthcare spaces for clients. Communication during exams is not limited to providing information or instructions – it is about working with the client to create a process that enhances their comfort and respects their autonomy. 

Gender-affirming relational practice and shared decision-making strategies support clients’ active participation in physical exams. Some strategies include: 

• Invite participation: Offer opportunities to pause, ask questions, or modify how the exam moves forward.

• Clarify and orient: Help clients know what to expect – what is happening, in what order and why.

• Check for consent: Use verbal check-ins, do not rely on silence or body language.

• Provide & respect choice: Choices might involve positions, draping, pacing or who is present during the exam.

• Honour autonomy: Remind clients that they are in control of the visit and can stop at any point, no matter what (2). 

Before the exam: Setting the tone

Not every person wants the same style of interaction. Some want detailed updates throughout while others want quiet and efficient exams (2). Asking clients about their communication preferences can help them feel more comfortable and in control of their healthcare experience (2).

The words we use and how we say them matter during client encounters (2). Being conscientious and using affirming language can impact a client's experience and potentially increase their engagement in health care (2,11). Best practices include:

During the exam: Providing support

Verbal and non-verbal responses during exams communicate volumes to clients (2). It is helpful to:

Clients who are experiencing distress may not vocalize this during an exam (2). Non-verbal cues that may indicate distress during an exam include:

If a client shows signs of distress or dissociation:

Clinicians can help clients feel more present during moments of discomfort or emotional overwhelm. Examples of grounding techniques include:

Post-exam care and follow-up

The care provided after a physical examination can be as important as the examination itself, particularly for clients who may have experienced it as challenging or distressing (2). Even a positive or affirming experience can leave someone feeling vulnerable.

Once the exam is over and the client is no longer physically exposed, take a moment to reconnect. You might say:

If the client experienced distress, help them plan what happens next, clinically and emotionally. This might include:

1. Makadon HJ, Mayer KH, Potter J, Goldhammer H, American College of Physicians, editors. The Fenway guide to lesbian, gay, bisexual, and transgender health. Second edition. Philadelphia: American College of Physicians; 2015. 

2. Peitzmeier SM, Potter J. Patients and their bodies: The physical exam. In: Eckstrand KL, Potter J, editors. Trauma, resilience, and health promotion in LGBT patients: What every healthcare provider should know. Cham: Springer International Publishing; 2017. pp. 191–202. doi:10.1007/978-3-319-54509-7_16

3. Strand N, Gomez DA, Kacel EL, Morrison EJ, St Amand CM, Vencill JA, et al. Concepts and approaches in the management of transgender and gender-diverse patients. Mayo Clin Proc. 2024;99: 1114–1126. doi:10.1016/j.mayocp.2023.12.027

4. James SE, Herman JL, Durso LE, Heng-Lehtinen R. Early insights: A report on the 2022 U.S. transgender survey. National Center for Transgender Equality; 2024. Available: https://transequality.org/sites/default/files/2024-02/2022%20USTS%20Early%20Insights%20Report_FINAL.pdf

5. Hastings J, Bobb C, Wolfe M, Amaro Jimenez Z, Amand CS. Medical care for nonbinary youth: Individualized gender care beyond a binary framework. Pediatr Ann. 2021;50: e384–e390. doi:10.3928/19382359-20210818-03

6. Trauma-informed practice guide. BC Provincial Mental Health and Substance Use Planning Committee; 2013. 

7. The Center for Health Care Strategies. What is trauma-informed care? In: Trauma-Informed Care Implementation Resource Center [Internet]. 2021 [cited 7 Apr 2025]. Available: https://www.traumainformedcare.chcs.org/what-is-trauma-informed-care/

8. Clark DBA, MacNeil L, Grieves L, Townsend M. Gender and sex data practices within electronic health records in a primary care setting: A use case approach. Can J Nurs Inform. 2022;18: 1–23. 

9. Alpert AB, Mehringer JE, Orta SJ, Redwood E, Hernandez T, Rivers L, et al. Experiences of transgender people reviewing their electronic health records, a qualitative study. J Gen Intern Med. 2023;38: 970–977. doi:10.1007/s11606-022-07671-6

10. Elwyn G, Frosch D, Thomson R, Joseph-Williams N, Lloyd A, Kinnersley P, et al. Shared decision making: A model for clinical practice. J Gen Intern Med. 2012;27: 1361–1367. doi:10.1007/s11606-012-2077-6

11. Klein A, Golub SA. Enhancing gender-affirming provider communication to increase health care access and utilization among transgender men and trans-masculine non-binary individuals. LGBT Health. 2020;7: 292–304. doi:10.1089/lgbt.2019.0294