Gender Inclusive Observations of Unsatisfactory ThinPrep Pap Tests (TPPT)

Summary: Introduction: Evidence has demonstrated that Papanicolou (Pap) tests (PT) from trans masculine individuals are more likely to have insufficient cells to render a diagnosis than PT from cisgender women (10.8% vs 1.3% of tests). Our institution sought to identify characteristics of ThinPrep PT (TPPT) in non-cisgender women in our patient population. Materials and Methods: The laboratory information system (LIS) was queried for TPPT cases between January 2022 and December 2023. 49,968 cases were identified. These were stratified first by the gender the patient used to identify themselves in the LIS (female, male, trans masculine (TM), non-binary (NB), other, and not disclosed (ND)). The cases were then stratified by the diagnosis (non-diagnostic, negative for intraepithelial lesion or malignancy (NILM), atypical squamous cells of undetermined significance (ASCUS), atypical glandular cells (AGUS), low-grade squamous intraepithelial lesion (LSIL), atypical squamous cells, cannot rule-out high-grade (ASC-H), or high-grade squamous intraepithelial lesion (HSIL). It was noted when clinical history provided use of exogenous testosterone. Results: Patients identifying as male were 0.07% (n=35) of the total TPPT, TM were 0.16% (n=79), ND were 0.31% (n=155), NB were 0.42% (n=212), and other were 0.21% (n=105). In combining the male and TM patients, 14.91% (n=17) were non-diagnostic, 81.58% (n=93) were NILM, 2.63% (n=3) were ASCUS, 0.88% (n=1) were LSIL, and 0% (n=0) were AGUS, ASC-H, or HSIL. 25.44% (n=29) of the male and TM combined patients had designated testosterone use on the provided clinical history, compared to 2.12% (n=10) in combined ND, NB, and other patients. Conclusions: The total unsatisfactory TPPT in the male and TM population at our institution exceeded that found in the literature. Use of exogenous hormone use may be under-reported in provided clinical histories. With improved reporting of patients' gender identity, as well as use of exogenous hormones, specific site sampled, and any surgical interventions, pathologists will have a more accurate picture to correlate with the morphology seen in TPPT of non-cisgender women.