Persistent Disparities in Cancer Screening Found Among Sexual and Gender Minority Populations

A large cross-sectional analysis has revealed persistent and concerning disparities in adherence to guideline-recommended cancer screening among sexual orientation and gender identity (SOGI) minority individuals in the United States, with the most striking gaps observed in breast and cervical cancer (search)Search disease screening.

The study, published in CANCER, a peer-reviewed journal of the American Cancer SocietyView company profile, analyzed data from the 2018–2022 Behavioral Risk Factor Surveillance System, a nationally representative annual telephone survey of US adults. Investigators assessed screening adherence among 663,924 respondents eligible for breast, cervical, or colorectal cancer (search)Search disease screening based on US Preventive Services Task Force (USPSTF) recommendations.

"Prior literature had suggested that health care access and utilization among this specific population is worse, so I wasn't all that surprised by the results. That said, it is sobering when — even after adjustments for demographic and socioeconomic factors — we see sexual orientation and gender identity still had an independent effect on screening compliance," said senior author Timothy M. Pawlik, MD, MPH, PhD, chair of the department of surgery and Urban Meyer III and Shelley Meyer Chair for Cancer Research at The Ohio State University Wexner Medical CenterView company profile.

Screening Disparities by the Numbers

Among the study cohort, 8,108 respondents (1.2%) identified as sexual orientation minorities and 2,315 (0.4%) identified as gender identity minorities. Two-thirds (67.9%) identified as white and one-third (33.5%) had been assigned male at birth.

Using multivariable models that adjusted for race, ethnicity, education, income, marital status, insurance type, employment status, and area of residence, researchers found that sexual orientation minority women had 16% lower adherence to breast cancer (search)Search disease screening (adjusted prevalence ratio [aPR] = 0.84; 95% CI, 0.77–0.92) and 8% lower adherence to cervical cancer (search)Search disease screening (aPR = 0.92; 95% CI, 0.87–0.97) compared with heterosexual women.

The disparities were even more pronounced for gender identity minority individuals, who demonstrated a 76% lower likelihood of adhering to breast cancer (search)Search disease screening (aPR = 0.24; 95% CI, 0.08–0.74) and a 42% lower likelihood of adhering to cervical cancer (search)Search disease screening (aPR = 0.58; 95% CI, 0.37–0.90) relative to cisgender individuals.

In contrast, colorectal cancer (search)Search disease screening adherence appeared slightly higher among sexual orientation minority men (aPR = 1.1; 95% CI, 1.00–1.21) and did not differ based on gender identity.

Structural Barriers and Access to Care

The analysis also documented disparities in healthcare access. A higher percentage of sexual orientation minority individuals than heterosexual respondents reported being uninsured (11.8% vs. 7.2%) and having no personal physician (18% vs. 12.9%). Among gender identity minority individuals, 17.9% reported having no personal physician compared with 2.2% of cisgender respondents, though insurance coverage did not differ significantly between these groups.

Up to 16% of SOGI individuals have reported discrimination in health care settings, and a similar percentage report avoiding health care because they anticipate mistreatment, according to study background. Prior research suggests SOGI individuals are at elevated risk for cancer due to multiple distinct but interconnected pathways, including structural barriers in the health care system, psychosocial stressors such as homophobia or transphobia, increased risk for exposure to HIV or HPV infections, and behaviors such as smoking or alcohol use that may be triggered by psychological stress.

Clinical Implications

Despite the differences in screening adherence, SOGI status did not appear associated with meaningful differences in cancer prevalence. However, Pawlik cautioned against interpreting this finding as reassuring.

"The findings have important clinical and public health implications," he said. "Even though we are glad we didn't see differences in cancer prevalence, we have to acknowledge that lower screening rates will place individuals at higher risk for being diagnosed with potentially more advanced cancers."

A Call for Multipronged Interventions

The researchers outlined several strategies to eliminate barriers and increase screening uptake. At the health system level, they recommend promoting gender-affirming environments through the use of nonheteronormative language and inclusive intake forms, and by offering alternative screening approaches such as self-collected HPV testing. Additional training should be offered to enhance clinician-patient communication about the importance of screening for SOGI individuals.

Insurers' coverage policies should ensure screening recommendations are based on anatomy rather than administrative gender records, and payers can expand coverage of gender-affirming and culturally competent preventive services.

At the policy level, researchers called on state and federal agencies to mandate inclusion of SOGI questions in cancer registries and national surveys, ensuring their processes capture current gender identity and sex assigned at birth. Addendums to national guidelines should explicitly address SOGI populations and ensure clinical messaging and public health campaigns de-gender screening recommendations.

"Hopefully the data presented in this study highlight the importance of this," Pawlik said. "Only by reporting and analyzing these data and raising social awareness of these specific disparities can we begin to formulate effective interventions."

The Clinician's Role

Pawlik emphasized that healthcare professionals must take an active role in addressing these gaps. "All health care professionals should be asking their patients if they have been screened," he said. "I'm always shocked by how frequently we don't ask the basic questions like, 'When did you last have a mammogram?' or 'When was your last colonoscopy?' For clinicians who have patients who are part of the sexual orientation or gender identity minority subgroup, a more detailed conversation is necessary about what organs need to be screened based on their sex assigned at birth and their current self-identified gender."

Future research should emphasize collection of prospective longitudinal data that can more firmly establish causal pathways between SOGI minority status and screening behavior, enabling development of care models and navigation programs that can improve cancer screening and surveillance, Pawlik added.