Brief Report
Pap Test Use Is Lower Among Female-to-Male Patients Than Non-Transgender Women

https://doi.org/10.1016/j.amepre.2014.07.031Get rights and content

Background

A paucity of empirical research to date has examined cervical cancer screening in female-to-male (FTM) transgender men who retain their natal reproductive structures compared to non-transgender women.

Purpose

To examine patient and provider characteristics associated with being up-to-date on Pap tests, with a focus on gender identity and sexual orientation.

Methods

Retrospective chart review of 5,232 patients (4,882 women, 350 FTM transgender men) at an urban community health center. All HIV-negative primary care patients aged 21–64 years (inclusive) with at least one medical visit during the 2012 calendar year and who had a cervix as of December 31, 2012, were included. Data were analyzed in 2013 using a multilevel logistic regression model nesting patients within providers.

Results

FTM patients were significantly less likely to be up-to-date on Pap tests (AOR=0.63, 95% CI=0.47, 0.85) compared to non-transgender women, after adjusting for individual- and provider-level factors. Behaviorally bisexual patients, compared to patients who had sex with men exclusively, were more likely to be up-to-date (AOR=1.73, 95% CI=1.32, 2.26); patients reporting only sex with women were not significantly more or less likely to be up-to-date (AOR=1.01, 95% CI=0.83, 1.23).

Conclusions

Transgender patients are not accessing the same level of preventive cervical screening care as non-transgender female patients. There is a need to better understand barriers to care in this population. Contrary to findings in other settings, history of sex with women was not negatively associated with Pap utilization.

Introduction

Scant research has addressed cervical cancer screening in female-to-male (FTM) transgender men. Transgender men are individuals assigned a female sex at birth who identify as men, transmen, or along a transmasculine spectrum; the majority retain a cervix and should undergo Pap testing. FTM individuals are often marginalized, lack access to health care, and may have unique barriers to receiving gynecologic examinations despite a higher prevalence of certain cervical cancer risk factors, such as smoking and sexual violence.1, 2 Understanding Pap utilization among transgender men is important.3 This study describes the prevalence of Pap test utilization among FTM compared to non-transgender female patients and examines predictors of adherence to Pap testing at Fenway Health (FH), an urban primary healthcare clinic in Boston MA that serves a large lesbian, gay, bisexual, and transgender (LGBT) patient population.4

Section snippets

Methods

This study was an observational retrospective chart review. Data were extracted from the electronic medical record (EMR) via electronic query and manual review of patient charts at FH in 2013. All HIV-negative primary care patients aged 21–64 years (inclusive) with a medical visit in 2012 and who had a cervix as of December 31, 2012, were included in the study. HIV-positive patients were excluded, as they follow different screening guidelines. The study was approved by the FH IRB.

Results

A total of 5,232 patients were included. Overall, 3,815 of patients (72.9%) were up-to-date with Pap testing (Table 2), and 3,590 (73.5%) female patients and 225 (64.3%) FTM patients were up-to-date. FTM patients had a 37% lower odds of being up-to-date compared to non-transgender female patients after adjustment for other variables. Additional factors negatively associated with being up-to-date were never having had sex or unknown sexual history (compared to sex exclusively with men); student

Discussion

The proportion of FTM patients who were up-to-date was 9.2 percentage points lower compared to non-transgender female patients, and being transgender was an independent predictor associated with a 37% lower odds of being up-to-date. Even at a clinic where providers have expertise caring for LGBT populations,4 transgender patients are not achieving screening rates equivalent to non-transgender women. There is a need to better understand barriers to care in this patient population.12, 13, 14

In

Acknowledgments

There are no conflicts of interest to declare. This work was funded through the FY 2012 Supplemental Funding for Quality Improvement in Health Centers grant (No. H80CS00303) provided by the Health Resources and Services Administration at the U.S. Department of Health and Human Services.

No financial disclosures were reported by the authors of this paper.

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      The HPV prevalence in self-collected vaginal swabs of transmasculine people (16%) also appears comparable to the prevalence in cisgender women [127]. The risk of cervical cancer may be higher in transmasculine people because of a lower number of people accessing screening programs [128]. In addition, testosterone therapy may lead to tissue epithelial atrophy and shrinkage in the genital tract, which may cause discomfort and pain upon speculum insertion and cervical screening [129].

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