Research Article
Gender Identity Disparities in Cancer Screening Behaviors

https://doi.org/10.1016/j.amepre.2017.11.009Get rights and content

Introduction

Transgender (trans) and gender-nonconforming adults have reported reduced access to health care because of discrimination and lack of knowledgeable care. This study aimed to contribute to the nascent cancer prevention literature among trans and gender-nonconforming individuals by ascertaining rates of breast, cervical, prostate, and colorectal cancer screening behaviors by gender identity.

Methods

Publicly available de-identified data from the 2014–2016 Behavioral Risk Factor Surveillance System surveys were utilized to evaluate rates of cancer screenings by gender identity, while controlling for healthcare access, sociodemographics, and survey year. Analyses were conducted in 2018.

Results

Weighted chi-square tests identified significant differences in the proportion of cancer screening behaviors by gender identity among lifetime colorectal cancer screenings, mammography tests, Pap tests, prostate-specific antigen tests, discussing prostate-specific antigen test advantages/disadvantages with their healthcare provider, and up-to-date colorectal cancer screenings and Pap tests (all p<0.048). Weighted logistic regressions found that although some differences based on gender identity were fully explained by covariates, gender-nonconforming individuals had reduced odds of ever having a sigmoidoscopy/colonoscopy compared to cisgender (cis) men (AOR=0.46) and cis women (AOR=0.43), whereas trans men were more likely to have an up-to-date colorectal cancer screening as compared to cis men (AOR=2.29) and cis women (AOR=1.97). Trans women were less likely than cis women to have ever had a mammography screening (AOR=0.33) and trans men were more likely than cis women to have an up-to-date mammography test (AOR=2.03). Finally, trans men and gender-nonconforming individuals had reduced odds of lifetime Pap tests versus cis women (AOR=0.50 and 0.20, respectively), and gender-nonconforming individuals had lower odds of being up-to-date for Pap tests (AOR=0.33; all p<0.05).

Conclusions

The findings indicate that gender identity disparities in cancer screenings persist beyond known sociodemographic and healthcare factors. It is critical that gender identity questions are included in cancer and other health-related surveillance systems to create knowledge to better inform healthcare practitioners and policymakers of appropriate screenings for trans and gender-nonconforming individuals.

Introduction

Transgender is an umbrella term that includes transgender (i.e., individuals whose gender identity is different from their sex assigned at birth) men, women, and gender-nonconforming (i.e., individuals who do not identify solely as male or female; e.g., non-binary, genderqueer, agender, bigender, or gender-fluid). Inclusion of gender identity measures in national surveillance and other data collection efforts is scarce and, as a result, rates of chronic illness and care utilization among transgender and gender-nonconforming (TGNC) individuals, including cancer, have not been established. The 2014 National Summit on Cancer in the LGBT Communities called for an increase in research on the cancer risks and screening disparities of lesbian, gay, bisexual, and transgender communities,1 projecting the prevalence of invasive cancer within the U.S. to rise to 2.3 million cases per year by 2030, a 45% increase in diagnosis.1 This is likely to disproportionately impact TGNC individuals, given the vulnerability and stigma they face within the U.S. healthcare system.2, 3 Many TGNC individuals report refusal of care (19%), harassment (28%), and lack of TGNC-knowledgeable providers (50%), and 28% cited discrimination as a primary reason for postponing care,3 although it is unknown if this included cancer screening.

Many transgender (trans) individuals seek medical care as part of gender affirmation, which can include services of mental health counseling, hormone replacement therapy, and various surgeries involving primary and secondary sex characteristics.4 Conversely, trans people may avoid care that is not gender affirming because of discomfort or distress (i.e., trans men and Pap tests).5, 6 For those who do seek care, clinicians may fail to provide appropriate cancer screenings on the basis of the patient’s anatomy, such as mammograms for patients of any gender with significant breast tissue or a family history of breast cancer, prostate screenings for trans women and GNC individuals assigned male at birth, and Pap tests for GNC individuals assigned female at birth and trans men who retain a cervix after gender affirmation. Thus, trans individuals may be particularly vulnerable to developing high-grade cancer cytology because of decreased clinical surveillance.7

Emerging research has found gender identity to be relevant to cancer screening. A study at Fenway Health found that trans men were less likely to be up to date (UTD) on Pap tests than cisgender (cis) women.8 Trans men and GNC individuals were also shown to have significantly lower proportions of regular Pap tests in an Internet-based convenience sample.9 Another Fenway Health study found that, of trans men who do receive Pap tests, they were ten times more likely than cis women to have inadequate tests (i.e., the cell sample taken was insufficient for laboratory testing),10 which may be associated with increased risk for developing high-grade cervical lesions at a later date.11, 12 Rates of mammography at an urban community health center in Massachusetts similarly found that trans patients were much less likely than cis women to follow clinical screening guidelines.13 In the only study to use population-level data, Narayan and colleagues14 found that trans patients were as likely to adhere to 2014 mammography screening guidelines as cis patients.

Though these findings indicate a general trend toward decreased cancer screening among trans individuals, generalizability has been limited to the clinics from which the samples were drawn. Apart from one study on breast cancer,14 national data on rates of cancer screening in more representative trans populations has not yet been analyzed. The Centers for Disease Control and Prevention’s 2014–2016 iterations of the Behavioral Risk Factor Surveillance System (BRFSS) is one of the first U.S. surveys to collect information on gender identity. The aim of the present study is to establish rates of cancer screening among trans women, trans men, and GNC individuals in a national sample. Further, the present study seeks to investigate how trans individuals’ screening rates compare with cis individuals.

Section snippets

Study Sample

Publically available population-level data from the 2014, 2015, and 2016 BRFSS were utilized to compare cancer-screening behaviors among cis and TGNC adults. Analyses were limited to 32 states that collected gender identity of TGNC individuals (593 trans men, 936 trans women, 384 GNC individuals, 249,017 cis women, and 192,670 cis men) (Table 1). The BRFSS is a system of national telephone surveys that collected demographic and health-related data on noninstitutionalized adult U.S. residents.15

Measures

Results

Table 1 shows the weighted percentages and chi-square results of sociodemographic variables, healthcare access variables, and survey year by gender identity. Trans men and GNC individuals tended to be younger, and TGNC individuals were generally more likely to identify as gay, bisexual, or other. The overall sample reflected high levels of being employed and was predominately white, with TGNC having a larger proportion of racial/ethnic minority representation. Cis men had the greatest

Discussion

First, weighted bivariate analyses indicated differences in the proportion of lifetime CRC screenings by gender identity. Trans women and GNC individuals reported the lowest proportion of UTD CRC screenings, and trans men reported higher or comparable rates of lifetime BST and sigmoidoscopy/colonoscopy compared with cis counterparts. Weighted multivariate analyses controlled for sociodemographic and healthcare access variables, which diminished some gender differences. For CRC screenings, trans

Conclusions

This study aimed to determine rates of cancer screening in a random sample of TGNC U.S. adults. Compared with cis individuals, trans women exhibited reduced lifetime mammography, trans men exhibited reduced lifetime Pap tests, and GNC individuals exhibited reduced lifetime endoscopy screenings and both lifetime and UTD Pap tests. Additional research is needed to identify correlates of these disparities, and more data are needed on cancer incidence and risk factors in TGNC populations to inform

Acknowledgments

MS is funded by the National Cancer Institute (R25CA090314). This article is solely the responsibility of the author and does not necessarily represent the official views of NIH.

All authors made the following significant contributions to the manuscript: AT contributed to conceptualization, methodology, writing of the original draft, review and editing of the original draft, supervision, and project administration; MS contributed to conceptualization, methodology, formal analysis, writing of the

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