Sexual and gender minority populations remain less likely to receive recommended breast and cervical cancer screening, highlighting ongoing healthcare disparities and the need for more inclusive, equitable preventive care.
Study: Sexual orientation and gender identity based disparities in colorectal, cervical, and breast cancer screening in the United States. Image credit: New Africa/Shutterstock.com
A recent study published in the journal Cancer found persistent disparities in screening rates for breast and cervical cancer among sexual orientation and gender identity (SOGI) minority populations.
Structural barriers limit equitable access to cancer screening
There are almost ten million deaths from cancer worldwide each year. In the USA alone, 1.8 million new cases of cancer were reported in 2022, while the next year, there were approximately 54,000 and 42,000 deaths from colorectal and female breast cancer, respectively. Cervical cancer claimed over 4,000 lives.
The US Preventive Services Task Force recommends routine screening for cervical, breast, and colorectal cancers because they have effective and inexpensive screening tests. However, structural barriers prevent the equitable use of screening services, including access issues and the impact of social determinants of health.
Sexual orientation and gender identity (SOGI) characterize several minorities that together comprise about 5.5% of the US adult population. These groups experience disparities in healthcare due to reasons like discrimination, too few professionals who are trained to deal appropriately with SOGI minorities, and systemic differences in healthcare delivery.
Previous research suggests they are more likely to have only public insurance, and to find healthcare access more difficult than others. Discrimination has been reported by up to 16%, and this may reduce the chances of others seeking healthcare, as reported by almost one in six of this group.
Several risk factors for cancer are more common among SOGI individuals, owing to multiple factors like structural discrimination, a history of sexual abuse, homophobia, and transphobia. Together, these may contribute to higher cancer risk. They increase their vulnerability to behaviors like smoking and drinking, and to obesity, as well as viruses like human papillomavirus (HPV) and HIV. These factors increase cancer risk.
The current study sought to assess how SOGI status was associated with screening rates for colorectal, cervical, and breast cancer screening.
Researchers analyzed screening patterns in diverse populations
The study included 663,924 respondents, of which only 25.9% completed the optional sexual orientation questions and were included in the sexual orientation analyses. Because the sexual orientation and gender identity questions were asked separately, the corresponding analyses used different denominators.
Most participants who responded were heterosexual (24.7%), while 1.2% belonged to a sexual orientation minority (SOM) group, and 0.4% identified as a gender identity minority (GIM). At-birth assigned gender was female in 51%, while 68% were White.
Minority groups faced greater healthcare access challenges
SOM were younger than heterosexual participants and more likely to be female. They were less likely to be insured (12% versus 7%, respectively). About 60% had a history of HIV testing versus 37% of heterosexual and 42% of GIM individuals.
SOM and GIM individuals were more likely to be from racial/ethnic minorities, with lower annual household income, and less likely to have their own physician, compared to heterosexual participants. However, insurance coverage was similar in GIM individuals.
Of the population analyzed for cancer prevalence, 7% and 0.6% identified as SOM and GIM, respectively, with 42% being female at birth and 64% White.
Cancer screening adherence
After adjustment for demographic and healthcare-related factors, sexual orientation minority (SOM) men were 10% more likely to be up to date with colorectal cancer screening than heterosexual men. However, no similar association was observed among SOM women, and gender identity minority (GIM) status was not independently associated with colorectal cancer screening adherence.
The clearest disparities were seen for cervical and breast cancer screening. Compared with heterosexual women, SOM women were 8% less likely to adhere to cervical cancer screening recommendations and 16% less likely to undergo recommended breast cancer screening.
Screening disparities were even greater among GIM individuals, who were 42% less likely to receive cervical cancer screening and 76% less likely to receive breast cancer screening than their cisgender counterparts.
Cancer prevalence
Although unadjusted analyses identified some differences in cancer prevalence between groups, these were not consistently maintained after adjustment for potential confounding factors.
Overall, adjusted analyses found no statistically significant association between SOM or GIM status and cervical or breast cancer prevalence. Likewise, no differences in cancer prevalence were observed between cisgender and GIM respondents within either birth-sex cohort.
Improving equitable cancer screening
The findings suggest that the lower screening rates observed among SOGI minority populations are more likely to reflect barriers to preventive healthcare than differences in cancer prevalence. To address these disparities, the authors propose creating more gender-affirming healthcare environments through inclusive language, revised intake forms, and additional clinician training.
They also suggest that self-collected HPV testing could improve cervical cancer screening uptake among eligible GIM individuals. At a broader level, they recommend incorporating SOGI questions into national surveys, cancer registries, public health campaigns, and clinical guidelines, while expanding insurance coverage and ensuring that screening recommendations are based on an individual's anatomy rather than gender identity alone. The authors also call for further research to better understand the factors contributing to lower screening adherence in these populations.
Self-reported data introduced potential sources of bias
The study was observational and cannot rule out confounding by multiple factors, such as self-reported data, recall bias, and misclassification error. The poorest strata may have been underrepresented due to the lack of adequate phone access. The SOGI population was small because this part of the form was optional and provided to the participants in certain states and years. No data were collected regarding gender transition.
Inclusive screening policies could improve preventive healthcare
According to the authors:
these results highlight persistent gaps in preventive cancer care for SOGI minority. Further research is needed to elucidate the drivers of these disparities and to inform targeted interventions that improve equitable access to preventive cancer services.
The findings suggest that screening recommendations should be based on the anatomy of the individual rather than gender identity alone, with more inclusive preventive care. This approach may help reduce disparities and support earlier cancer detection among sexual and gender minority populations.
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