Disparities in Cervical Cancer Screening Use By Sexual Orientation: Results from the National Health Interview Survey

Background and Purpose

Routine screening for cervical cancer via pap test is recommended for all women, but recent studies suggest that lesbians and bisexual (LB) women are less likely to undergo pap tests compared to heterosexual women. This disparity is not well understood. Previous studies have found that disparate use of reproductive health services (commonly accessed through obstetrician/gynecologist, or OB/GYN, visits) may drive this trend, but it is not clear what role access to healthcare plays. The aim of this study was to determine whether disparities in pap test use would be explained by OB/GYN visits once both sociodemographic factors and healthcare access were controlled.

Methods

Data were from the National Health Interview Survey (2013-2015). Female respondents ages 21-64 with no previous cervical cancer diagnosis were included. Descriptive statistics (frequencies), bivariate analyses (chi-square tests), and multivariate analyses (logistic regression predicting pap test use in the past 12 months) were conducted (Model 1=sociodemographics; Model 2=sociodemographics, healthcare access; Model 3=sociodemographics, healthcare access, healthcare utilization).

Results

Respondents (N=39,085) were 78% white, 14% black, and 8% “other” race. 64% were married, most had some college or a Bachelor’s degree (68%), and 14% reported less than federal poverty level income. Most identified as heterosexual, 1.7% (n=649) identified as lesbian, and 1.1% (n=457) identified as bisexual.

Pap test use varied by sexual orientation; 56%, 48%, and 50% of heterosexual, lesbian, and bisexual women were tested, respectively (p=.002). In terms of healthcare access, LB women were more likely to report cost-related barriers (p<.001) to receiving healthcare compared to heterosexual women and were less likely to have a place to go for preventive care (p<.001). LB women were less likely to see an OB/GYN doctor in the past 12 months compared to heterosexual women (p<.001).

When sociodemographic factors were controlled (Model 1: marital status, age, race/ethnicity, education, and poverty level), pap test disparities persisted. Compared to heterosexual women, the adjusted odds of receiving a pap test were 0.68 for lesbians (p=.001) and 0.72 for bisexual women (p=.016). While the addition of healthcare access variables (Model 2: insurance type, cost-related barriers, and place for preventive care) somewhat attenuated the disparity in pap test use for both bisexual women (AOR=0.76, p=.065) and lesbians (AOR=0.72, p=.006), it did not fully explain the disparity. With the addition of seeing an OB/GYN in the 3^rd model, the difference in pap test use by sexual orientation was no longer significant for either lesbians (AOR=0.86, p=.202) or bisexual women (AOR=0.83, p=.240).

Conclusions and Implications

LB women were less likely to complete pap tests compared to heterosexual women even when both sociodemographic factors and access to care were controlled, but this disparity was attenuated by visiting an OB/GYN. Our results suggest that factors other than healthcare access are driving OB/GYN visits and pap test use. Previous studies suggest that fear of discrimination and discomfort disclosing sexual orientation to healthcare provider may influence OB/GYN and pap test use among LG women. Social workers can play a role in promoting healthcare equity for LB women.