Adjusted logistic regressions suggest there are meaningful differences in breast and cervical cancer screening compliance before and during the COVID-19 pandemic across gender identity. Almost all groups saw a decrease in screening compliance for both breast and cervical cancer once the pandemic began. Compared to cisgender women, TGD respondents were more likely to be non-compliant with breast cancer screening recommendations before and during COVID-19. Our point estimates suggest that the disparity in breast cancer screening compliance increased during the pandemic. These results are consistent with previous studies showing that TGD patients are less likely to adhere to mammography screening guidelines than cisgender patients.[4], [5] Additionally, these results are consistent with the framework proposed by Zubizarreta et al., highlighting how COVID-19 may disproportionately impact TGD populations[17].
Compared to before the COVID-19 pandemic, during the pandemic a greater proportion of both cisgender women and trans men were noncompliant with cervical cancer screenings, indicating the impact that the pandemic had on both groups. However, adjusted odds ratios show that during the pandemic, trans men were more likely to be noncompliant with cervical cancer screening recommendations compared to cis women, potentially pointing to the disproportionate impact of this pandemic on trans men. These results are consistent with previous studies that found transgender men are less likely to be up-to-date on their Pap tests compared to cisgender women[21]. The large confidence intervals suggest that these results should be interpreted cautiously, and may explain some of the inconsistencies observed with previous studies[8], [9]. Unstable estimates are to be expected with small sample sizes, and yet, there are few large studies that gather gender identity data, so this is to be expected until such data are routinely collected.
Due to limited sample sizes, we were only able to calculate adjusted odds ratios for cervical cancer screening compliance comparing gender non-conforming respondents to cisgender women during COVID-19. Our results show that gender non-conforming people are less likely to be non-compliant with cervical cancer screening recommendations than cisgender women. Previous studies have not collected information on gender non-conforming people and population-level estimates on cervical cancer screening compliance are not currently available.
This is one of the first studies to examine the impact of COVID-19 on breast and cervical cancer screening compliance in TGD and cisgender individuals across the U.S. Delayed care can lead to poorer health outcomes[22]. If cancer is detected later, it could mean that patients are diagnosed at more severe stages and have lower chances of survival.
Limitations
BRFFS data can be made more representative of the U.S. population via data weighting, however, this process relies on the existing sex variable, which may misclassify participants, especially TGD participants[20]. Since this study does not rely on the weighting system, the study sample can be thought of more as a convenience sample, and therefore may not be a representative sample. For the 2018, 2019, 2020, and 2021 surveys, BRFFS asks participants ‘Are you male or female?’ and interviews are terminated with participants who refuse to answer or report “don’t know/not sure”[23]. TGD participants may have been less likely to answer this resulting in non-response bias, or they may have answered based on their gender, resulting in misclassification.
Questions regarding breast cancer, cervical cancer, and hysterectomies are only asked to participants who report being ‘female’ which may have resulted in biased estimates by excluding or including certain participants. In the future, we recommend that BRFSS utilize a two-step[24] item to assess sex assigned at birth and gender identity for all participants. Questions regarding gender-affirming surgeries and hormone therapy are not asked in these versions of BRFFS, which could impact screening recommendations, and therefore compliance[2].
Because of the aggregated ages reported in the publicly available version of the data and the small counts, it is impossible to assess cervical cancer screening compliance for individuals 21–24 years old, despite screening being recommended for this age group. The reported cancer diagnosis relies on the most recently reported diagnosis of cancer. If participants have had breast or cervical cancer, but have been diagnosed with another cancer more recently, the survey would not capture that information, causing misclassification.
Future work
Although, it is an important first step to catalog the compliance across different gender identities, future research should focus on explanatory factors for the differences observed between breast and cervical cancer screening across gender identity. Gaining a better understanding of why differences exist will allow for tailored interventions. Additional work should continue to dismantle systems of oppression, including transphobia, that are a major contributor to health disparities.