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. 2014 Feb;104(2):e68–e73. doi: 10.2105/AJPH.2013.301548

Sexual Orientation Disparities in Papanicolaou Test Use Among US Women: The Role of Sexual and Reproductive Health Services

Madina Agénor 1,✉, Nancy Krieger 1, S Bryn Austin 1, Sebastien Haneuse 1, Barbara R Gottlieb 1
PMCID: PMC3935675  PMID: 24328650

Abstract

We investigated sexual orientation disparities in Papanicolaou screening among US women aged 21 to 44 years (n = 9581) in the 2006 to 2010 National Survey of Family Growth. The odds ratios for lesbian versus heterosexual women and women with no versus only male sexual partners were 0.40 and 0.32, respectively, and were attenuated after adjustment for sexual and reproductive health (SRH) care indicators. Administering Papanicolaou tests through mechanisms other than SRH services would promote cervical cancer screening among all women.

Cervical cancer, a deadly disease primarily caused by human papillomavirus infection,1 can be prevented through regular Papanicolaou (Pap) test use and appropriate follow-up.2,3 Although lesbians and women who have sex with women are at risk for human papillomavirus4–14 from both past and present sexual partners, limited evidence derived from convenience15,16 and subnational population-based16,17 samples suggests that they are less likely than heterosexual women and women with only male sexual partners, respectively, to receive Pap tests.8,9,15,17–22 We accordingly investigated sexual orientation disparities in Pap test use in a large US national probability sample, which no previous study has done, and assessed the contribution of sexual and reproductive health (SRH) services to sexual orientation disparities in Pap test use.

METHODS

We analyzed data from the 2006 to 2010 National Survey of Family Growth, which provides a nationally representative US sample of 10 403 men and 12 279 women aged 15 to 44 years.23,24 We restricted our analysis to women aged 21 years and older (n = 9581), in line with the American Congress of Obstetricians and Gynecologists’ cervical cancer screening guidelines during the study period.25

The outcome was Pap test use in the past 12 months, and the predictors were sexual orientation identity and sex of sexual partners in the past year (shown with their categorization in Table 1). Covariates were social and economic factors and health care indicators, including the use of SRH services (Table 1). We excluded 299 women (3.1%) from multivariable analyses because of missing data.

TABLE 1—

Distribution of US Women Aged 21–44 Years by Sexual Orientation Identity and Sex of Sexual Partners in the Past Year by Social, Economic, and Health Care Factors: National Survey of Family Growth, 2006–2010

Sexual Orientation Identity
 Sex of Sexual Partners in the Past Year
Variable Total (n = 9581), % Heterosexual (n = 8838; 92.3%), % Bisexual (n = 410; 4.3%), % Lesbian (n = 151; 1.6%), % Male Only (n = 8129; 84.9%), % Male and Female (n = 309; 3.2%), % Female Only (n = 145; 1.5%), % No Partners (n = 998; 10.4%), %
Pap test in past 12 mo 68.0 68.5 64.5 43.3 70.7 66.7 46.0 43.9
Age, y
 21–29 38.4 37.5 62.2 44.9 37.5 57.4 42.6 41.3
 30–44 61.6 62.5 37.8 55.1 62.5 42.6 57.4 58.8
Race/ethnicity
 White 61.3 61.5 73.8 50.8 61.2 71.9 56.2 59.1
 Black 13.5 13.4 11.9 21.1 13.2 14.3 19.4 15.4
 Latina/Hispanic 16.6 16.5 7.7 16.0 17.1 7.4 12.2 14.5
 “Other”/“multiracial” 8.7 8.6 6.7 12.0 8.5 6.5 12.3 11.0
Place of residence
 MSA, central city 32.5 31.8 43.1 52.3 31.7 40.5 56.5 35.5
 MSA, other 47.7 48.0 39.9 45.0 48.1 43.0 39.6 45.9
 Non-MSA 19.8 20.2 17.0 2.7 20.2 16.5 3.9 18.6
Relationship status
 Married 51.4 52.3 37.3 5.6 57.2 31.2 0.8 4.4
 Not married, living with a male partner 12.4 12.2 18.5 1.3 13.6 15.2 1.4 0.6
 Separated, divorced, or widowed 11.4 11.4 13.3 10.1 9.7 11.8 19.6 27.9
 Never married 24.9 24.0 30.9 82.9 19.5 41.8 78.2 67.1
Language
 English 92.9 93.2 98.6 94.8 92.4 99.5 98.9 95.1
 Spanish 7.1 6.8 1.4 5.3 7.6 0.5 1.1 4.9
US-born 83.4 83.7 92.8 80.9 83.5 93.1 88.2 78.8
Educational attainment
 < high school degree 14.8 14.2 21.4 10.3 15.1 17.3 9.7 11.2
 High school diploma or GED 24.4 24.2 30.5 28.0 24.6 33.5 22.1 20.0
 Some college/associate’s degree 30.2 30.2 35.9 27.6 29.7 33.5 28.8 33.8
 ≥ bachelor’s degree 30.7 31.5 12.3 34.1 30.6 15.7 39.3 35.0
Household income, % federal poverty level
 < 100 20.4 19.8 25.9 18.4 20.0 19.9 18.6 24.6
 100–199 22.8 22.9 20.8 15.5 22.6 29.4 15.8 24.6
 200–299 18.5 18.2 23.4 24.4 18.3 17.3 24.2 19.9
 ≥ 300 38.4 39.0 29.9 41.6 39.2 33.5 41.4 30.9
Employment status
 Working 72.6 72.92 67.8 84.2 72.3 70.7 84.6 75.7
 Not working 23.7 23.43 28.0 14.2 24.3 26.1 13.8 18.3
 Student 3.7 3.65 4.3 1.7 3.5 3.2 1.6 6.1
Health insurance status
 Private 62.4 63.6 45.4 58.8 63.1 50.8 60.6 59.8
 Public 16.0 15.3 28.1 22.6 15.9 19.6 15.3 15.8
 Uninsured, single-service plan, or Indian Health Service 21.6 21.1 26.5 18.6 21.0 29.6 24.2 24.5
Received a contraceptive method or prescription for a method in the past y 33.7 34.0 35.7 11.3 35.6 39.5 7.9 16.7
Received STI counseling, testing, or treatment in the past y 15.9 15.4 28.6 14.3 16.6 32.0 10.6 4.5
Ever pregnant 74.3 74.7 71.2 33.9 77.6 71.4 28.0 46.2
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Note. GED = general equivalency diploma; MSA = metropolitan statistical area; NSFG = National Survey of Family Growth; Pap = Papanicolau; STI = sexually transmitted infection. Missing data was < 1.0% for Pap test in the last 12 months, language, US nativity, receiving a contraceptive method or prescription for a method in the past year, and receiving STI counseling, testing, or treatment in the past year. Missing data was 1.9% for sexual orientation identity. Sex of sexual partners in the past year had no missing values among women aged 21–44 years. Missing values for age, race/ethnicity, relationship status, place of residence, household income, educational attainment, employment status, and health insurance status were multiply imputed by the NSFG; ever being pregnant was computed by the NSFG and had no missing data. Prevalence estimates were adjusted for the NSFG’s complex sampling design and weighted to the US population with Stata 12.26 Percentages may not add to 100% because of rounding.

We used logistic regression to model the relationship between each measure of sexual orientation and Pap test use. After fitting bivariate models, we first added social and economic factors, followed by health care indicators. We tested for possible interactions between sexual orientation and receiving contraception as well as ever having been pregnant; we retained only statistically significant interaction terms (P < .05) in the final models. All analyses were weighted for the survey’s complex sampling design with Stata 12.26

RESULTS

Table 1 presents sample characteristics by sexual orientation. Pap test use was lowest among lesbians (43.3%) and women with no sexual partners in the past year (43.9%). Table 2 shows that after adjustment for social and economic factors (models 2a and 2b), the odds of Pap test use were lower among lesbians than heterosexual women (odds ratio [OR] = 0.40; 95% confidence interval [CI] = 0.23, 0.68) and lower among women with no sexual partners than women with only male sexual partners (OR = 0.32; 95% CI = 0.25, 0.42).

TABLE 2—

Results of Multivariable Analysis for the Odds of Receiving a Papanicolau Test in the Past 12 Months Among US Women Aged 21–44 Years by Sexual Orientation Identity and Sex of Sexual Partners in the Past Year by Social, Economic, and Health Care Factors: National Survey of Family Growth, 2006–2010

Sexual Orientation Identity
 Sex of Sexual Partners in the Past Year
Variable Model 1aa OR (95% CI) Model 2ab OR (95% CI) Model 3ac OR (95% CI) Model 4ad OR (95% CI) Model 1ba OR (95% CI) Model 2bb OR (95% CI) Model 3bc OR (95% CI) Model 4bd OR (95% CI)
Sexual orientation identity
 Heterosexual (Ref) 1.00 1.00 1.00 1.00
 Bisexual 0.84 (0.58, 1.22) 0.85 (0.58, 1.22) 0.81 (0.54, 1.22) 1.78 (0.89, 3.54)
 Lesbian 0.35 (0.21, 0.58) 0.40 (0.23, 0.68) 0.56 (0.28, 1.12) 0.85 (0.45, 1.61)
Sex of past-y sexual partners
 Male only (Ref) 1.00 1.00 1.00 1.00
 Male and female 0.83 (0.57, 1.20) 0.84 (0.58, 1.22) 0.77 (0.49, 1.22) 1.01 (0.44, 2.32)
 Female only 0.35 (0.22, 0.57) 0.32 (0.19, 0.54) 0.62 (0.35, 1.09) 0.62 (0.34, 1.14)
 No partners 0.32 (0.26, 0.41) 0.32 (0.25, 0.42) 0.54 (0.43, 0.69) 0.36 (0.25, 0.53)
Social and economic factors
Age, y
 21–29 (Ref) 1.00 1.00 1.00 1.00 1.00 1.00
 30–39 0.75 (0.63, 0.88) 1.11 (0.92, 1.35) 1.10 (0.91, 1.34) 0.79 (0.67, 0.93) 1.14 (0.94, 1.39) 1.14 (0.93, 1.38)
Race/ethnicity
 White (Ref) 1.00 1.00 1.00 1.00 1.00 1.00
 Black 1.57 (1.25, 1.97) 1.66 (1.28, 2.14) 1.65 (1.28, 2.13) 1.48 (1.19, 1.83) 1.60 (1.25, 2.05) 1.58 (1.23, 2.02)
 Latina/Hispanic 0.98 (0.77, 1.25) 1.05 (0.79, 1.39) 1.05 (0.79, 1.40) 0.94 (0.74, 1.19) 1.01 (0.77, 1.33) 1.01 (0.77, 1.33)
 “Other”/“multiracial” 0.84 (0.61, 1.14) 1.03 (0.75, 1.40) 1.02 (0.75, 1.40) 0.80 (0.59, 1.10) 0.98 (0.72, 1.32) 0.98 (0.72, 1.33)
Place of residence
 MSA, central city (Ref) 1.00 1.00 1.00 1.00 1.00 1.00
 MSA, other 0.85 (0.71, 1.02) 0.85 (0.72, 1.01) 0.85 (0.72, 1.01) 0.85 (0.72, 1.01) 0.85 (0.71, 1.00) 0.85 (0.72, 1.00)
 Non-MSA 0.98 (0.79, 1.23) 1.13 (0.89, 1.45) 1.14 (0.89, 1.45) 1.01 (0.82, 1.24) 1.16 (0.92, 1.47) 1.16 (0.92, 1.46)
Relationship status
 Married (Ref) 1.00 1.00 1.00 1.00 1.00 1.00
 Not married, living with a male partner 1.29 (1.02, 1.63) 1.09 (0.81, 1.46) 1.09 (0.81, 1.46) 1.33 (1.05, 1.67) 1.09 (0.82, 1.45) 1.09 (0.82, 1.45)
 Separated, divorced, or widowed 0.89 (0.69, 1.13) 0.84 (0.65, 1.10) 0.85 (0.65, 1.11) 1.13 (0.87, 1.46) 0.95 (0.73, 1.25) 0.90 (0.69, 1.18)
 Never married 0.67 (0.55, 0.80) 0.63 (0.52, 0.75) 0.63 (0.52, 0.76) 0.89 (0.75, 1.06) 0.72 (0.60, 0.88) 0.74 (0.61, 0.90)
Language
 English (Ref) 1.00 1.00 1.00 1.00 1.00 1.00
 Spanish 1.20 (0.85, 1.71) 1.55 (1.04, 2.33) 1.56 (1.04, 2.34) 1.12 (0.78, 1.62) 1.50 (1.00, 2.23) 1.49 (1.00, 2.21)
Nativity
 US-born (Ref) 1.00 1.00 1.00 1.00 1.00 1.00
 Not US-born 0.71 (0.55, 0.92) 0.77 (0.59, 1.00) 0.77 (0.59, 1.00) 0.80 (0.63, 1.01) 0.83 (0.65, 1.06) 0.83 (0.65, 1.07)
Educational attainment
 < high school diploma 0.64 (0.49, 0.83) 0.71 (0.52, 0.95) 0.71 (0.53, 0.95) 0.61 (0.47, 0.79) 0.71 (0.53, 0.95) 0.71 (0.53, 0.95)
 High school diploma or GED 0.70 (0.57, 0.86) 0.81 (0.65, 1.01) 0.82 (0.66, 1.01) 0.66 (0.54, 0.82) 0.81 (0.65, 1.00) 0.80 (0.64, 0.99)
 Some college/associate’s degree 0.88 (0.73, 1.07) 0.96 (0.77, 1.18) 0.95 (0.77, 1.18) 0.85 (0.70, 1.03) 0.95 (0.77, 1.16) 0.94 (0.76, 1.57)
 ≥ bachelor’s degree (Ref) 1.00 1.00 1.00 1.00 1.00 1.00
Household income, % federal poverty level
 < 100 0.71 (0.58, 0.88) 0.72 (0.58, 0.90) 0.72 (0.58, 0.89) 0.72 (0.58, 0.88) 0.74 (0.59, 0.92) 0.74 (0.59, 0.92)
 100–199 0.59 (0.48, 0.74) 0.63 (0.50, 0.80) 0.62 (0.49, 0.79) 0.61 (0.49, 0.76) 0.66 (0.51, 0.84) 0.66 (0.51, 0.84)
 200–299 0.72 (0.59, 0.87) 0.73 (0.59, 0.92) 0.73 (0.58, 0.91) 0.75 (0.61, 0.91) 0.76 (0.60, 0.95) 0.76 (0.60, 0.95)
 ≥ 300 (Ref) 1.00 1.00 1.00 1.00 1.00 1.00
Employment status
 Working (Ref) 1.00 1.00 1.00 1.00 1.00 1.00
 Not working 0.76 (0.66, 0.87) 0.85 (0.72, 1.00) 0.85 (0.72, 1.00) 0.75 (0.65, 0.87) 0.84 (0.71, 0.99) 0.84 (0.72, 1.00)
 Student 0.99 (0.68, 1.45) 1.03 (0.71, 1.49) 1.04 (0.71, 1.50) 1.01 (0.72, 1.42) 1.07 (0.74, 1.54) 1.10 (0.76, 1.57)
Health care indicators
Health insurance status
 Private (Ref) 1.00 1.00 1.00 1.00
 Public 1.03 (0.81, 1.32) 1.03 (0.81, 1.31) 1.03 (0.81, 1.31) 1.02 (0.80, 1.30)
 Uninsured, single-service plan, or Indian Health Service 0.43 (0.35, 0.53) 0.43 (0.35, 0.52) 0.42 (0.35, 0.51) 0.42 (0.34, 0.51)
Received a contraceptive method or prescription for a method in the past y
 Yes 6.60 (5.37, 8.12) 6.79 (5.46, 8.44) 6.34 (5.16, 7.78) 6.22 (5.06, 7.63)
 No (Ref) 1.00 1.00 1.00 1.00
Received STI counseling, testing, or treatment in the past y
 Yes 4.69 (3.50, 6.29) 4.68 (3.49, 6.24) 4.33 (3.25, 5.75) 4.28 (3.22, 5.69)
 No (Ref) 1.00 1.00 1.00 1.00
Ever pregnant
 Yes 1.29 (1.04, 1.60) 1.37 (1.11, 1.70) 1.23 (1.00, 1.51) 1.12 (0.89, 1.41)
 No (Ref) 1.00 1.00 1.00 1.00
Interaction terms
Sexual orientation identity × contraception
 Bisexual × contraception 0.83 (0.31, 2.21)
 Lesbian × contraception 0.15 (0.03, 0.77)
Sexual orientation identity × ever pregnant
 Bisexual × ever pregnant 0.37 (0.18, 0.78)
 Lesbian × ever pregnant 0.57 (0.18, 1.80)
Sex of sexual partners × ever pregnant
 Male and female × ever pregnant 0.69 (0.26, 1.78)
 Female only × ever pregnant 0.84 (0.24, 2.91)
 No partners × ever pregnant 2.26 (1.37, 3.75)
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Note. CI = confidence interval; GED = general equivalency diploma; MSA = metropolitan statistical area; NSFG = National Survey of Family Growth; OR = odds ratio; STI = sexually transmitted infection. The total sample was n = 9581. Missing data was < 1.0% for Papanicolau test in the last 12 months, language, US nativity, receiving a contraceptive method or prescription for a method in the past year, and receiving STI counseling, testing, or treatment in the past year. Missing data was 1.9% for sexual orientation identity. Sex of sexual partners in the past year had no missing values among women aged 21–44 years. Missing values for health insurance status were multiply imputed by the NSFG. All ORs and 95% CIs were adjusted for the NSFG’s complex sampling design and weighted to the US population with Stata 12.26

a

Unadjusted for any covariates.

b

Adjusted for social and economic factors.

c

Added adjustment for health care indicators.

d

Added adjustment for statistically significant (P < .05) interaction of sexual orientation and reproductive health services use.

Including health care indicators (models 3a and 3b) attenuated the odds ratios for lesbians relative to heterosexual women (OR = 0.56; 95% CI = 0.28, 1.12) and women with no relative to only male sexual partners (OR = 0.54; 95% CI = 0.43, 0.69). In these fully adjusted models, obtaining contraceptive and sexually transmitted infection services in the past year was positively associated with Pap test use among all women. However, including interaction terms (model 4a) showed that receiving contraception was positively associated with Pap test use among heterosexual (OR = 6.79; 95% CI = 5.46, 8.44) and bisexual (OR = 10.03; 95% CI = 1.51, 66.03) women only; having ever been pregnant was positively associated with Pap test use among heterosexual women only (OR = 1.37; 95% CI = 1.11, 1.70; Table 2). Similarly to contraceptive and sexually transmitted infection services use, the odds of Pap test use did not differ by pregnancy history among women with only male (OR = 1.12; 95% CI = 0.89, 1.41), both male and female (OR = 0.78; 95% CI = 0.10, 5.82), only female (OR = 0.58; 95% CI = 0.07, 4.68), and no (OR = 0.91; 95% CI = 0.31, 2.80) sexual partners in the past year (model 4b).

DISCUSSION

Our findings provide the first national estimates of the relationship between sexual orientation and Pap test use among US women aged 21 to 44 years, derived from cross-sectional, self-report data. They also indicate that observed sexual orientation disparities in Pap test use may be linked to differentials in SRH services use. Indeed, lesbians and women with no sexual partners in the past year were less likely than heterosexual women and women with only male sexual partners, respectively, to have received contraceptive and sexually transmitted infection services and to have ever been pregnant. Because reproductive health represents an important entry point into the health care system for women, lesbians and women with no sexual partners in the past year have fewer opportunities to obtain a Pap test.

One implication of our findings is that health care facilities should also administer Pap tests through mechanisms other than SRH services, such as during routine primary care visits and regular cervical cancer screening clinics for underscreened women or through mobile health care vans that provide Pap tests in women’s communities. In addition, because some research suggests that lesbians may prefer receiving care from general practitioners rather than obstetrician-gynecologists,27 it may be beneficial to improve the capacity of general practitioners to provide Pap tests, in light of evidence that they are less likely than obstetrician-gynecologists to provide cervical cancer screening and other SRH services.28–32 Finally, because human papillomavirus risk is linked to women’s past and present male and female sexual partners,12,33 increasing Pap test use among women who identify as lesbian or currently have no sexual partners will likely require programs—for both women and health care providers—that promote knowledge of human papillomavirus risk across the life course among women of all sexual orientations.34–37

Acknowledgments

Data analyses and article preparation were supported by the Stephen B. Kay Family Public Health Scholarship, Harvard School of Public Health, awarded to M. Agénor. S. B. Austin is supported by the Maternal and Child Health Bureau, Health Resources and Services Administration (training grant MC00001) and Leadership Education in Adolescent Health Project (6T71-MC00009).

A previous version of this article was presented at the 140th American Public Health Association Annual Meeting; October 27–31, 2012; San Francisco, CA.

We are grateful to the 2006 to 2010 National Survey of Family Growth participants and the anonymous reviewers who provided helpful feedback on the article.

Human Participant Protection

This study was approved by the office of human research administration, Harvard School of Public Health.

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