Management of Clitoral Pain in FTM Transgender Patients

Gender-Affirming Care Considerations

The American College of Physicians, as reflected in the Mayo Clinic Proceedings, recommends using the patient's preferred terminology when discussing anatomy to reduce psychological distress and improve pain outcomes 1, 2, 3
A trauma-informed approach, as suggested by the Mayo Clinic Proceedings, involves conducting examinations with explicit permission, allowing the patient to guide contact and maintain control, and offering chaperone services and appropriate pain control procedures 1, 2, 4

Testosterone therapy can modulate pain perception, with some FTM patients reporting improvement in pre-existing pain conditions after starting testosterone, according to the Mayo Clinic Proceedings 5, 4
The Mayo Clinic Proceedings notes that gender identity appears to play a more significant role in pain sensation than sex assigned at birth 2, 5

The Mayo Clinic Proceedings suggests addressing psychosexual concerns and screening for comorbid anxiety, depression, and substance use, which are more prevalent in transgender populations and affect pain management 1, 6
Affirming the patient's gender identity, as recommended by the Mayo Clinic Proceedings, reduces psychological distress and improves pain outcomes 1, 2

The Mayo Clinic Proceedings advises against discontinuing testosterone without thorough evaluation, as this may worsen gender dysphoria and overall quality of life 1, 4
The Mayo Clinic Proceedings recommends avoiding making the patient remove gender-affirming garments unnecessarily during examination, as this triggers dysphoria 7
The Mayo Clinic Proceedings notes that there is documented bias and undertreatment of pain in transgender patients, and therefore recommends against undertreating pain in this population 1, 2

The Centers for Disease Control and Prevention recommends evaluating for infectious etiologies, including sexually transmitted infections, if the patient is sexually active, particularly if there is urethral involvement or dysuria 8, 9
The British Journal of Dermatology suggests screening for dermatologic conditions such as lichen sclerosus, which can cause genital pain, scarring, and dyspareunia in individuals with vulvar anatomy 10

The Mayo Clinic recommends discussing harm reduction strategies for gender-affirming practices, such as chest binding or genital tucking, which can cause pain but should not be discouraged 11, 12
The National Comprehensive Cancer Network recommends vaginal estrogen therapy as the first-line treatment for vaginal dryness and painful intercourse caused by testosterone-induced atrophy 13
The Centers for Disease Control and Prevention recommends obtaining urethral swab or first-void urine for gonorrhea and chlamydia testing and initiating empiric treatment with ceftriaxone and doxycycline if urethritis or sexually transmitted infection is suspected 8, 14

The British Journal of Dermatology recommends performing a biopsy to confirm diagnosis of lichen sclerosus and initiating treatment with ultra-potent topical corticosteroids 10

The National Comprehensive Cancer Network suggests considering referral to a sexual health specialist for comprehensive management when pain persists despite initial interventions 13
The British Journal of Dermatology recommends addressing psychosexual concerns, as chronic genital pain significantly impacts quality of life and sexual functioning 10

The Mayo Clinic recommends offering a chaperone of the patient's preferred gender to create a safer environment during examination 15