Participation, Barriers, and Facilitators of Cancer Screening Among LGBTQ+ Populations: A Review of the Literature

Abstract

ABSTRACT Compared with cisgender and heterosexual individuals, members of the LGBTQ+ community experience worse health outcomes. This is due to a combination of structural inequities and life experiences, including higher rates of mental illness and suicidality, sexually transmitted infections, and certain cancers. Men who have sex with men are at higher risk of anal cancer, and lesbian and bisexual women are often diagnosed with breast cancer at younger ages than heterosexual women partly due to lower parity and higher bodyweight. Despite these increased risks, some evidence shows the LGBTQ+ population is less likely to participate in early detection and cancer screening programs; however, the etiology of this is unknown. This review aims to summarize the current literature on cancer screening uptake in the LGBTQ+ population, including barriers and facilitators associated with screening participation. Studies published between January 2001 and April 2022 involving individuals identified as a gender or sexual minority that assessed participation in and/or facilitators and barriers to a cancer screening procedure were included. Barriers and facilitators identified in quantitative studies were reported on the individual-, provider-, and administrative/system-level scale. A total of 50 publications were included, 38 of which were quantitative, 10 were qualitative, and 2 used mixed methods. Among 16 relevant studies, considerable variation was identified when analyzing whether sexual minority women had lower participation in cervical cancer screening programs. Among 15 studies assessing the participation of sexual minority women compared with heterosexual women in breast cancer screening, 5 studies found no difference, whereas the remainder suggested lower rates of screening among sexual minority women. Fewer studies assessed screening among sexual minority men; however, sexual minority men were more likely to report anal cancer screening than heterosexual men. Cervical cancer screening participation among transgender men and gender diverse participants was lower than cisgender participants in almost all studies. Of 9 studies reporting breast cancer screening among gender diverse or transgender individuals, 5 found lower participation among transgender or gender diverse individuals compared with cisgender women. One study identified greater odds of up-to-date mammography among transgender men compared with cisgender women. The most common individual-level barriers to screening are related to knowledge of the screening tests themselves, including screening guidelines, procedures, pain, embarrassment, and a fear of results. One of the strongest correlates in studies was perceived discrimination from health care providers, which often resulted in lack of disclosure of sexual orientation or gender identity. Provider-level factors mostly included provider communication and relationship with the patient, and patients preferred providers experienced with LGBTQ+ clients and that used sexuality-inclusive language. Having open communication about sexual orientation and gender identity was a positive facilitator for all patients. System-level barriers included inclusive documentation and physical environments in health care. This review highlights key disparities including the lower screening rates among transgender patients in all categories and lower screening rates for cervical cancer and mammography among sexual minority women. It also highlights a significant need for representative data on all LGBTQ+ populations.