Correlates of underutilization of gynecological cancer screening among lesbian and heterosexual women

Abstract

Background. Study aims were to examine cervical cancer risk factors, screening patterns, and predictors of screening adherence in demographically similar samples of lesbian (N = 550) and heterosexual women (N = 279).

Methods. Data are from a multisite survey study of women's health conducted from 1994 to 1996.

Results. Differences in sexual behavior risk factors for cervical cancer were observed with lesbians reporting earlier onset of sexual activity (P < 0.05), more sexual partners (P < 0.001), and lower use of safer sex activities (P < 0.01). Lesbian and heterosexual women were equally likely to have ever had a Pap test; however, lesbians were less likely to report annual (P < 0.001) or routine (P < 0.001) testing. Multivariate analyses were used to determine the associations between demographics, health care factors, health behaviors, and worry about health and screening behaviors. Individual predictors of never screening included younger age, lower income, and lack of annual medical visits. Independent predictors of both recent and annual screenings included history of an abnormal Pap test, being heterosexual, and annual medical visits.

Conclusion. Data indicate that lesbians are at risk for cervical cancer, yet underutilize recommended screening tests. Findings have implications for research, education, and cancer control among lesbians.

Introduction

Cervical cancer incidence and mortality rates have decreased substantially over the past five decades due to widespread screening with the Papanicolaou (Pap) test [1]. Routine screening with Pap tests have increased the likelihood of detecting preinvasive lesions or early-stage disease resulting in survival rates of over 90% in women falling into those diagnostic categories [2]. Despite these gains, estimates for 2003 suggest that 12,200 women will be diagnosed with cervical cancer and about 4,100 women will die as a result of the disease [2]. Cervical cancer incidence and mortality rates have been shown to vary based on demographic characteristics such as racial and ethnic minority group membership and lower education and socioeconomic status [3], [4]. Identification of additional subpopulations in which cervical cancer disparities exist and the development of strategies to increase adherence to established guidelines for cervical cancer screening can further reduce the incidence and mortality associated with this largely preventable disease [2], [5].

A recent report by the Gay and Lesbian Medical Association suggests that sexual orientation may be an important contributor to health disparities in the United States [6]. To better understand the role of sexual orientation in cervical cancer risk, the aims of this study were to identify and compare cervical cancer risk factors in a demographically similar sample of lesbian and heterosexual women, measure adherence to established guidelines for cervical cancer screening, and identify variables associated with adherence to screening guidelines.

New guidelines released by the ACS recommend annual Pap tests for all women starting 3 years after the onset of sexual intercourse, or by age 21 [7]. For women over age 30, Pap tests may be conducted less frequently (every 2–3 years) if they have had three consecutive normal Pap results [7]. Data from population-based national surveys show an increase in cervical cancer screening rates among U.S. women [8]. Rates of recent Pap tests (within the past 3 years) among women aged 25 years and older range from 75% of Behavioral Risk Factor Surveillance System (BRFSS) participants to 82% of National Health Interview Survey (NHIS) respondents [8], [9]. Variability in rates of screening based on age, race/ethnicity, income, education, presence of usual source of care and access to health insurance were observed in both studies [8], [9].

Disparities in cancer screening rates have also been observed based on sexual orientation [10]. Findings from several studies suggest lower rates of cervical cancer screening among lesbian women [11], [12], [13], [14], [15]. As with heterosexual women, cervical cancer screening by lesbians is strongly associated with demographic characteristics with more educated, higher-income, and older lesbians more likely to engage in routine Pap screening [13]. Lower utilization of cervical cancer screening tests among lesbians has been associated with lower perceived cancer risk and negative experiences in health care settings [13], [14].

The extant literature suggests that lesbians may face challenges in adherence to cancer screening activities that differ from those experienced by heterosexual women. For example, unique barriers for lesbians include physician ignorance regarding lesbian health issues [16], discrimination in health care settings [17], decreased access to preventive and treatment services [18], mistrust of the medical establishment [19], and lack of insurance coverage or access to partner benefits [11]. Combined, the above factors may act as formidable barriers to some lesbians' access to critical preventive health care and treatment services [16].

Beyond increasing adherence to screening recommendations, reducing cancer risk behaviors is an essential component of cancer prevention and control [5]. Cervical cancer is closely linked to failure to receive regular Pap tests, exposure to certain strains of the human papillomavirus (HPV), infection with other sexually transmitted diseases, older age, cigarette smoking, immunosuppressive disorders such as HIV/AIDS, and sexual risk behaviors [20]. Sexual risk factors include early initiation of sexual intercourse, multiple male sexual partners, and sex with male partners who have had multiple sexual partners [20], [21], [22]. Although lesbians receive inconsistent messages about their risk for cervical cancer, documented risks for cervical cancer among lesbians include higher rates of tobacco use, multiple past sexual partners, sexual intercourse with men, early age at first sexual intercourse, history of sexually transmitted disease, the presence of HPV, and low screening rates [11], [13], [14], [23].

In summary, studies suggest that like heterosexual women, a constellation of factors may play a role in lesbians' risk for the development of cervical cancer. However, little is known about whether the risk and protective factors for cervical cancer or predictors of cancer screening differ for lesbian and heterosexual women. A recent report by the Institute of Medicine [10] underscores the importance of understanding the role of sexual orientation in health behaviors. Such information is necessary in delivering effective health to improve the health of all women.