Abstract
Objective
Lesbian and bisexual women are at risk for human papillomavirus (HPV) infection and cervical disease. We examined Pap testing among these women and their acceptability of HPV self-testing at home, a potential cervical cancer screening strategy.
Methods
We analyzed data from a national sample of lesbian and bisexual women ages 21–26 who completed our online survey during Fall 2013 (n=418). Logistic regression identified correlates of: 1) receipt of a Pap test in the last three years; and 2) willingness to use an HPV self-test at home.
Results
About 70% of women had received a Pap test in the last three years. Pap testing was more common among women who had disclosed their sexual orientation to their healthcare provider (OR=2.01, 95% CI: 1.02–3.95) and less common among women who self-identified as lesbian (OR=0.48, 95% CI: 0.25–0.93). Just over half of women (51%) were willing to use an HPV self-test at home. Women were more willing to use an HPV self-test at home if they were older (OR=1.16, 95% CI: 1.03–1.30) or reported higher levels of worry about getting an HPV-related disease (OR=1.28, 95% CI: 1.01–1.63). The most common concerns about HPV self-testing at home were using the test incorrectly (70%) and test accuracy (64%).
Conclusions
Many young lesbian and bisexual women have not received a recent Pap test. HPV self-testing at home may be a promising future strategy for reaching and screening these women. Findings highlight beliefs and concerns that could be addressed by self-test programs.
Keywords: Cervical cancer, Screening, HPV, Lesbian and bisexual women
INTRODUCTION
Persistent infection with oncogenic human papillomavirus (HPV) types causes virtually all cervical cancers.[1] Cervical cancer is largely preventable through regular screening,[2] yet over 12,000 new cases of cervical cancer and over 4,000 deaths from cervical cancer are expected to occur among women in the United States (US) during 2014.[3] Current cervical cancer screening guidelines recommend women ages 21–29 receive cytology (i.e., Pap testing) every three years, and women ages 30–65 receive a combination of cytology and HPV testing every 5 years (preferred strategy) or cytology every 3 years (acceptable strategy).[4] HPV testing is therefore currently recommended as a cervical cancer screening “cotest”, but there is interest in HPV testing as a primary screening option. Indeed, the Food and Drug Administration (FDA) recently approved an HPV test as a primary cervical cancer screening option for women starting at age 25.[5]http://www.medpagetoday.com/OBGYN/GeneralOBGYN/44745
Given the current and potential future role of HPV testing in cervical cancer screening, it is important to examine HPV self-testing as a screening option for women. HPV self-tests involve women using a device on their own to collect a specimen for HPV testing. HPV self-tests are currently not licensed for use in the US but have high enough accuracy to be considered as a viable screening strategy in the future.[6] The sensitivity and specificity of HPV self-tests (sensitivity=86%, specificity=81%) for detecting cervical intraepithelial neoplasia grade 2 or more severe compare favorably to liquid-based cytology (sensitivity=81%, specificity=94%) and physician-collected specimens for HPV testing (sensitivity=97%, specificity=83%).[6] In an attempt to reach women without a recent Pap test, international studies have successfully mailed HPV self-tests to women at home and had them use and return a self-test device (up to 34% of women used and returned their HPV self-test).[7] Less, however, is known about HPV self-testing at home among women in the US, though most are willing to use an HPV self-test.[8–10]
Lesbian and bisexual women are at risk for HPV infection and cervical disease since HPV can be transmitted between female sexual partners[11] and many of these women have current or past male sexual partners from whom they could have acquired HPV.[12] Past research suggests that up to 30% of lesbian and bisexual women have a current genital HPV infection (about 43% of all US women have a current infection).[11,13,14] Furthermore, about 20% of young adult lesbian and bisexual women report a history of cervical abnormalities, which is comparable to young adult heterosexual women (also about 20%).[15] It is therefore recommended that all women, regardless of sexual orientation, follow the same cervical cancer screening recommendations.[16]
Although relatively few studies have examined cervical cancer screening among lesbian and bisexual women,[15,17–22] most have found that women who have sex with women, especially lesbians, are less likely to have a recent Pap test compared to heterosexual women.[15,17,20,21] One potential explanation for this disparity in cervical cancer screening is that lesbian and bisexual women utilize sexual and reproductive health services (e.g., oral contraceptive services) less frequently than heterosexual women.[17] Thus, HPV self-testing at home may be a promising strategy for reaching and screening lesbian and bisexual women for cervical cancer. However, no studies, to our knowledge, have examined acceptability of HPV self-testing at home among lesbian and bisexual women.
The current study examined Pap testing behaviors among a national sample of young lesbian and bisexual women. We also examined their willingness to use an HPV self-test at home and concerns they would have about using a self-test at home. Results will be highly useful for future programs to increase cervical cancer screening among lesbian and bisexual women.
METHODS
Study Design
We conducted a cross-sectional study with individuals who were: 1) ages 18–26; 2) lived in the US; and 3) self-identified as lesbian, gay, bisexual, or transgender (LGBT).[23] Participants were members of an online LGBT specialty panel that is a subset of the Harris Interactive Online Panel. Harris Interactive constructs this voluntary research panel through online and offline recruitment strategies throughout the US. In exchange for completing multiple online surveys each month, panel members receive points that can later be redeemed for rewards. The Institutional Review Board at The Ohio State University approved the study.
Of 2,014 panel members who were confirmed eligible for the study, 1,005 (50%) provided consent and completed our online survey in October and November 2013. In the present study, we report data from women ages 21–26 who self-identified as lesbian or bisexual (n=418). We exclude data from 125 female respondents ages 18–20 since cervical cancer screening is not currently recommended for females younger than age 21. Women included in the current study were from 48 states and the District of Columbia.
Measures
Outcome Variables
We examined two main outcomes: 1) whether women had received a Pap test within the last three years (i.e., within the current recommended screening guidelines for this age range[4]); and 2) women’s willingness to use an HPV self-test at home. Women were classified as having either received a Pap test in the last three years (i.e., a recent Pap test) or not. If women indicated they had not received a Pap test in this timeframe, a survey question then asked the main reason why they had not. Women could indicate only one main reason, and survey software rotated the order of response options. Among all women, we assessed how willing they would be to use an HPV self-test at home. We provided a brief description of the HPV self-test to women, indicating that it is a cervical cancer screening test that they would complete by themselves at home and mail the collected specimen to their doctor. Response options included “definitely not willing”, “probably not willing”, “not sure”, “probably willing”, and “definitely willing.” We classified women as “willing” (definitely or probably willing: coded as 1) or “not willing” (all other responses: coded as 0). The survey then asked all women what concerns they would have about using an HPV self-test at home. Women could indicate multiple responses from a list of potential concerns.
Correlates
The survey assessed a wide range of demographic and health-related characteristics as potential correlates. We examined age at sexual debut, number of lifetime sexual partners, and history of any sexually transmitted infection (STI). We also assessed health insurance coverage, receipt of a routine check-up in past year, and if women had received any doses of HPV vaccine. Survey questions asked if women had disclosed their sexual orientation to their healthcare provider and whether they thought they had ever been discriminated against by a healthcare provider because of their sexual orientation,[24] both of which are important issues for this population.[25]
The survey assessed knowledge and beliefs about HPV and HPV-related disease using items from our previous studies.[26–28] We calculated an HPV knowledge score based on the proportion of correct responses to six true/false statements (possible range=0–1). The survey assessed women’s worry about getting HPV-related disease (1 item, possible range=1–4), perceived severity of HPV-related disease (1 item, possible range=1–4), and perceived likelihood of cervical cancer (1 item, possible range=1–4). The survey also assessed whether women perceived a lower risk of cervical cancer compared to heterosexual women (1 item, possible range=1–5). All continuous variables were coded so that higher values indicate greater levels of that construct.
Data Analysis
We used logistic regression to identify correlates of our two main outcomes: 1) receipt of a Pap test in the last three years; and 2) willingness to use an HPV self-test at home. For each outcome, we entered all statistically correlates (p<0.05) from univariable models into a multivariable model to produce adjusted odds ratios (ORs) and 95% confidence intervals (CIs). We used descriptive statistics to examine reasons why women had not received a Pap test in the last three years and women’s concerns about using an HPV self-test at home. We used chi-square tests to determine if these outcomes differed between lesbian and bisexual women. We conducted all analyses in Stata IC version 13 (Statacorp, College Station, TX) using two-tailed tests and a critical alpha of 0.05.
RESULTS
Participant Characteristics
Most women were non-Hispanic white (68%), not married or living with a partner (60%), and reported a household income of less than $50,000 (69%; Table 1). About 73% of women self-identified as bisexual, and 27% self-identified as lesbian. Participants’ mean age was 23.8 years (standard deviation[SD]=1.7 years). About half of women had a college degree (52%). Women had moderate knowledge about HPV (mean=0.62, SD=0.28) but tended to report low levels of worry about getting HPV-related disease (mean=1.8, SD=0.9) and perceived likelihood of cervical cancer (mean=2.2, SD=0.6). Women generally believed that getting an HPV-related disease would be severe (mean=3.5, SD=0.7).
Table 1.
Demographic characteristics of lesbian and bisexual women, n=418
| n (%) | |
|---|---|
| Sexual identity | |
| Bisexual | 307 (73) |
| Lesbian | 111 (27) |
| Age (range 21–26), mean (SD) | 23.8 (1.7) |
| Race/Ethnicity | |
| Non-Hispanic White | 286 (68) |
| Non-Hispanic Black | 45 (11) |
| Hispanic | 53 (13) |
| Other race/ethnicity | 34 (8) |
| Education | |
| Less than college | 71 (17) |
| Some college | 128 (31) |
| College degree or more | 219 (52) |
| Marital status | |
| Never married, divorced, widowed, separated | 250 (60) |
| Married, civil union, living with a partner | 168 (40) |
| Employment status | |
| Currently employed | 241 (58) |
| Not employed | 87 (21) |
| Student | 90 (22) |
| Annual household income | |
| <$50,000 | 289 (69) |
| ≥$50,000 | 100 (24) |
| Not reported | 29 (7) |
| Urbanicity | |
| Rural | 83 (20) |
| Suburban | 177 (42) |
| Urban | 158 (38) |
Note. Percentages may not sum to 100% due to rounding. SD=standard deviation.
Pap Testing
Overall, 70% (291/418) of women had received a Pap test within the last three years. Among those who had received a Pap test in the last three years, 67% (195/291) had done so in the last year. About 24% of women (101/418) had never received a Pap test. The most common main reasons why women had not received a Pap test in the last three years were cost (21%), embarrassment (20%), lack of a healthcare provider recommendation (13%), and believing a Pap test is not necessary because they did not have any health problems (11%). All other reasons were reported by less than 10% of women. Reasons for not having a Pap test in the last three years did not differ between lesbian and bisexual women (all p>0.05).
In multivariable analyses (Table 2), Pap testing in the last three years was more common among women who were older (OR for 1-year increase=1.21, 95% CI: 1.02–1.43), had their own health insurance (OR=2.13, 95% CI: 1.09–4.16), had a routine check-up in the past year (OR=2.41, 95% CI: 1.38–4.21), had received at least one dose of HPV vaccine (OR=2.63, 95% CI: 1.47–4.70), or had disclosed their sexual orientation to their healthcare provider (OR=2.01, 95% CI: 1.02–3.95). Compared to women who reported having no lifetime sexual partners, Pap testing in the last three years was more common among those who reported 1–4 sexual partners (OR=8.08, 95% CI: 2.79–23.42) or five or more sexual partners (OR=17.06, 95% CI: 5.62–51.77). Women who self-identified as lesbian (OR=0.48, 95% CI: 0.25–0.93) or were Hispanic (compared to non-Hispanic whites; OR=0.30, 95% CI: 0.14–0.63) were less likely to have had a Pap test in the last three years.
Table 2.
Correlates of Pap testing in the last three years among lesbian and bisexual women, n=418
| Pap test in last 3 years | No Pap test in last 3 years | Univariable | Multivariable | |||
|---|---|---|---|---|---|---|
| n (%) | n (%) | OR | (95% CI) | OR | (95% CI) | |
| Overall | 291 (70) | 127 (30) | -- | -- | ||
| Demographic characteristics | ||||||
| Sexual identity | ||||||
| Bisexual | 223 (73) | 84 (27) | Ref | Ref | ||
| Lesbian | 68 (61) | 43 (39) | 0.60 | (0.38–0.94)* | 0.48 | (0.25–0.93)* |
| Age (years)a | 24.0 (1.6) | 23.4 (1.7) | 1.25 | (1.10–1.42)*** | 1.21 | (1.02–1.43)* |
| Race/Ethnicity | ||||||
| Non-Hispanic White | 215 (75) | 71 (25) | Ref | Ref | ||
| Non-Hispanic Black | 29 (64) | 16 (36) | 0.60 | (0.31–1.17) | 0.84 | (0.35–2.04) |
| Hispanic | 27 (51) | 26 (49) | 0.34 | (0.19–0.63)*** | 0.30 | (0.14–0.63)** |
| Other race/ethnicity | 20 (59) | 14 (41) | 0.47 | (0.23–0.98)* | 0.56 | (0.22–1.42) |
| Education | ||||||
| Less than college | 47 (66) | 24 (34) | Ref | -- | ||
| Some college | 77 (60) | 51 (40) | 0.77 | (0.42–1.41) | -- | |
| College degree or more | 167 (76) | 52 (24) | 1.64 | (0.91–2.93) | -- | |
| Marital status | ||||||
| Never married, divorced, widowed, separated | 158 (63) | 92 (37) | Ref | Ref | ||
| Married, civil union, living with a partner | 133 (79) | 35 (21) | 2.21 | (1.41–3.48)** | 1.53 | (0.86–2.71) |
| Employment status | ||||||
| Currently employed | 174 (72) | 67 (28) | Ref | -- | ||
| Not employed | 60 (69) | 27 (31) | 0.86 | (0.50–1.46) | -- | |
| Student | 57 (63) | 33 (37) | 0.67 | (0.40–1.11) | -- | |
| Annual household income | ||||||
| <$50,000 | 200 (69) | 89 (31) | Ref | -- | ||
| ≥$50,000 | 71 (71) | 29 (29) | 1.09 | (0.66–1.79) | -- | |
| Not reported | 20 (69) | 9 (31) | 0.99 | (0.43–2.26) | -- | |
| Urbanicity | ||||||
| Rural | 55 (66) | 28 (34) | Ref | -- | ||
| Suburban | 124 (70) | 53 (30) | 1.19 | (0.68–2.08) | -- | |
| Urban | 112 (71) | 46 (29) | 1.24 | (0.70–2.19) | -- | |
| HPV knowledge and beliefs | ||||||
| HPV knowledgea,b | 0.65 (0.26) | 0.54 (0.31) | 4.05 | (1.92–8.52)*** | 2.16 | (0.84–5.56) |
| Worry about getting HPV-related diseasea,c | 1.9 (0.9) | 1.7 (0.8) | 1.29 | (1.00–1.67) | -- | |
| Perceived severity of HPV-related diseasea,d | 3.6 (0.6) | 3.5 (0.8) | 1.08 | (0.80–1.46) | -- | |
| Perceived likelihood of cervical cancera,e | 2.2 (0.6) | 2.1 (0.6) | 1.13 | (0.79–1.62) | -- | |
| Perceived lower risk of cervical cancer compared to heterosexual womena,f | 2.5 (1.0) | 2.7 (1.0) | 0.80 | (0.65–0.98)* | 1.00 | (0.77–1.32) |
| Health-related characteristics | ||||||
| Age at sexual debut | ||||||
| ≤ 17 years | 189 (78) | 53 (22) | Ref | Ref | ||
| ≥ 18 years | 102 (58) | 74 (42) | 0.39 | (0.25–0.59)*** | 0.75 | (0.42–1.34) |
| Number of lifetime sexual partners | ||||||
| None | 7 (19) | 30 (81) | Ref | Ref | ||
| 1–4 partners | 97 (63) | 58 (37) | 7.17 | (2.96–17.36)*** | 8.08 | (2.79–23.42)*** |
| ≥ 5 partners | 187 (83) | 39 (17) | 20.55 | (8.42–50.15)*** | 17.06 | (5.62–51.77)*** |
| Ever told by a provider that had an STI | ||||||
| No | 249 (68) | 118 (32) | Ref | Ref | ||
| Yes | 42 (82) | 9 (18) | 2.21 | (1.04–4.69)* | 1.02 | (0.41–2.50) |
| Insurance status | ||||||
| No health insurance | 58 (57) | 44 (43) | Ref | Ref | ||
| Insures self (work, school, etc.) | 134 (79) | 35 (21) | 2.90 | (1.69–4.99)*** | 2.13 | (1.09–4.16)* |
| Insured through parent’s plan | 99 (67) | 48 (33) | 1.56 | (0.92–2.64) | 1.49 | (0.76–2.92) |
| Had a routine check-up in past year | ||||||
| No | 131 (59) | 90 (41) | Ref | Ref | ||
| Yes | 160 (81) | 37 (19) | 2.97 | (1.90–4.65)*** | 2.41 | (1.38–4.21)** |
| Received any shots of HPV vaccine | ||||||
| No | 151 (63) | 89 (37) | Ref | Ref | ||
| Yes | 140 (79) | 38 (21) | 2.17 | (1.39–3.39)** | 2.63 | (1.47–4.70)** |
| Disclosed sexual orientation to healthcare provider | ||||||
| No | 158 (66) | 81 (34) | Ref | Ref | ||
| Somewhat | 29 (58) | 21 (42) | 0.71 | (0.38–1.32) | 0.63 | (0.29–1.37) |
| Yes | 104 (81) | 25 (19) | 2.13 | (1.28–3.56)** | 2.01 | (1.02–3.95)* |
| Discriminated against by healthcare provider | ||||||
| No | 235 (69) | 108 (31) | Ref | -- | ||
| Yes | 30 (81) | 7 (19) | 1.97 | (0.84–4.63) | -- | |
| Don’t know | 26 (68) | 12 (32) | 1.00 | (0.48–2.05) | -- | |
Note. Multivariable model included all variables associated at p<0.05 in univariable models. Dashes (--) indicate that variable was not included in the multivariable model. OR=odds ratio; CI=confidence interval; HPV=human papillomavirus; ref=reference group; STI=sexually transmitted infection.
Means and standard deviations are reported for continuous variables. ORs for these variables are for a 1-unit increase.
Measured by determining proportion of correct responses to six HPV knowledge items
4-point response scale ranging from 1=“not at all” to 4=“a lot”
4-point response scale ranging from 1=“not at all” to 4=“very”
4-point response scale ranging from 1=“no chance” to 4=“high chance”
5-point response scale ranging from 1=“strongly disagree” to 5=“strongly agree”
p<0.05;
p<0.01;
p<0.001
HPV Self-Testing
Just over half of women (51%; 212/418) were classified as willing to use an HPV self-test at home (24% indicated “definitely willing” and 27% indicated “probably willing”). Of the 49% of women who were classified as not willing to use an HPV self-test at home, 11% indicated “definitely not willing”, 16% indicated “probably not willing”, and 22% indicated “not sure”. In multivariable analyses (Table 3), women were more willing to use an HPV self-test at home if they were older (OR for 1-year increase =1.16, 95% CI: 1.03–1.30) or reported higher levels of worry about getting an HPV-related disease (OR=1.28, 95% CI: 1.01–1.63). Willingness to use an HPV self-test at home was nearly identical among women who had a Pap test within the last three years (51%) and those without a recent Pap test (51%)( p=0.90).
Table 3.
Correlates of willingness to use an HPV self-test at home, n=418
| Willing to use HPV self-test at home | Not willing to use HPV self-test at home | Univariable | Multivariable | |||
|---|---|---|---|---|---|---|
| n (%) | n (%) | OR | (95% CI) | OR | (95% CI) | |
| Overall | 212 (51) | 206 (49) | -- | -- | ||
| Demographic characteristics | ||||||
| Sexual identity | ||||||
| Bisexual | 157 (51) | 150 (49) | Ref | -- | ||
| Lesbian | 55 (50) | 56 (50) | 0.94 | (0.61–1.49) | -- | |
| Age (years)a | 24.0 (1.7) | 23.5 (1.7) | 1.19 | (1.06–1.34)* | 1.16 | (1.03–1.30)* |
| Race/Ethnicity | ||||||
| Non-Hispanic White | 143 (50) | 143 (50) | Ref | -- | ||
| Non-Hispanic Black | 23 (51) | 22 (49) | 1.05 | (0.56–1.96) | -- | |
| Hispanic | 28 (53) | 25 (47) | 1.12 | (0.62–2.01) | -- | |
| Other race/ethnicity | 18 (53) | 16 (47) | 1.13 | (0.55–2.29) | -- | |
| Education | ||||||
| Less than college | 37 (52) | 34 (48) | Ref | -- | ||
| Some college | 65 (51) | 63 (49) | 0.95 | (0.53–1.69 | -- | |
| College degree or more | 110 (50) | 109 (50) | 0.93 | (0.54–1.58) | -- | |
| Marital status | ||||||
| Never married, divorced, widowed, separated | 123 (49) | 127 (51) | Ref | -- | ||
| Married, civil union, living with a partner | 89 (53) | 79 (47) | 1.16 | (0.79–1.72) | -- | |
| Employment status | ||||||
| Currently employed | 122 (51) | 119 (49) | Ref | -- | ||
| Not employed | 45 (52) | 42 (48) | 1.05 | (0.64–1.71) | -- | |
| Student | 45 (50) | 45 (50) | 0.98 | (0.60–1.58) | -- | |
| Annual household income | ||||||
| <$50,000 | 142 (49) | 147 (51) | Ref | -- | ||
| ≥$50,000 | 54 (54) | 46 (46) | 1.22 | (0.77–1.92) | -- | |
| Not reported | 16 (55) | 13 (45) | 1.27 | (0.60–2.74) | -- | |
| Urbanicity | ||||||
| Rural | 39 (47) | 44 (53) | Ref | -- | ||
| Suburban | 93 (53) | 84 (47) | 1.25 | (0.74–2.11) | -- | |
| Urban | 80 (51) | 78 (49) | 1.16 | (0.68–1.97) | -- | |
| HPV knowledge and beliefs | ||||||
| HPV knowledgea,b | 0.65 (0.28) | 0.58 (0.28) | 2.39 | (1.20–4.79)* | 1.97 | (0.95–4.10) |
| Worry about getting HPV-related diseasea,c | 2.0 (0.9) | 1.7 (0.8) | 1.40 | (1.12–1.76)** | 1.28 | (1.01–1.63)* |
| Perceived severity of HPV-related diseasea,d | 3.6 (0.6) | 3.5 (0.7) | 1.19 | (0.89–1.58) | -- | |
| Perceived likelihood of cervical cancera,e | 2.2 (0.6) | 2.1 (0.6) | 1.15 | (0.83–1.60) | -- | |
| Perceived lower risk of cervical cancer compared to heterosexual womena,f | 2.5 (1.0) | 2.6 (1.0) | 0.89 | 0.74–1.08) | -- | |
| Health-related characteristics | ||||||
| Age at sexual debut | ||||||
| ≤ 17 years | 124 (51) | 118 (49) | Ref | -- | ||
| ≥ 18 years | 88 (50) | 88 (50) | 0.95 | (0.65–1.40) | -- | |
| Number of lifetime sexual partners | ||||||
| None | 18 (49) | 19 (51) | Ref | -- | ||
| 1–4 partners | 72 (46) | 83 (54) | 0.92 | (0.45–1.88) | -- | |
| ≥ 5 partners | 122 (54) | 104 (46) | 1.24 | (0.62–2.48) | -- | |
| Ever told by a provider that had an STI | ||||||
| No | 184 (50) | 183 (50) | Ref | -- | ||
| Yes | 28 (55) | 23 (45) | 1.21 | (0.67–2.18) | -- | |
| Insurance status | ||||||
| No health insurance | 54 (53) | 48 (47) | Ref | -- | ||
| Insures self (work, school, etc.) | 87 (51) | 82 (49) | 0.94 | (0.58–1.54) | -- | |
| Insured through parent’s plan | 71 (48) | 76 (52) | 0.83 | (0.50–1.38) | -- | |
| Had a routine check-up in past year | ||||||
| No | 115 (52) | 106 (48) | Ref | -- | ||
| Yes | 97 (49) | 100 (51) | 0.89 | (0.61–1.31) | -- | |
| Most recent Pap test | ||||||
| More than 3 yrs. ago or never | 65 (51) | 62 (49) | Ref | -- | ||
| Within last 3 yrs. | 147 (51) | 144 (49) | 0.97 | (0.64–1.48) | -- | |
| Received any shots of HPV vaccine | ||||||
| No | 120 (50) | 120 (50) | Ref | -- | ||
| Yes | 92 (52) | 86 (48) | 1.07 | (0.73–1.58) | -- | |
| Disclosed sexual orientation to healthcare provider | ||||||
| No | 120 (50) | 119 (50) | Ref | -- | ||
| Somewhat | 24 (48) | 26 (52) | 0.92 | (0.50–1.68) | -- | |
| Yes | 68 (51) | 61 (49) | 1.11 | (0.72–1.70) | -- | |
| Discriminated against by healthcare provider | ||||||
| No | 165 (48) | 178 (52) | Ref | Ref | ||
| Yes | 22 (60) | 15 (40) | 1.58 | (0.79–3.15) | 1.33 | (0.65–2.71) |
| Don’t know | 25 (66) | 13 (34) | 2.07 | (1.03–4.19)* | 2.00 | (0.97–4.12) |
Note. Multivariable model included all variables associated at p<0.05 in univariable models. Dashes (--) indicate that variable was not included in the multivariable model. OR=odds ratio; CI=confidence interval; HPV=human papillomavirus; ref=reference group; STI=sexually transmitted infection.
Means and standard deviations are reported for continuous variables. ORs for these variables are for a 1-unit increase.
Measured by determining proportion of correct responses to six HPV knowledge items
4-point response scale ranging from 1=“not at all” to 4=“a lot”
4-point response scale ranging from 1=“not at all” to 4=“very”
4-point response scale ranging from 1=“no chance” to 4=“high chance”
5-point response scale ranging from 1=“strongly disagree” to 5=“strongly agree”
p<0.05;
p<0.01;
p<0.001
The most common concerns women reported about using an HPV self-test at home were concerns about using the test incorrectly (70%), the test might not be accurate (64%), would rather go to a doctor to get screened for cervical cancer (44%), the test might hurt (25%), and would not want to return a completed test through the mail (23%). All other concerns were reported by less than 10% of women. Concerns about using an HPV self-test at home did not differ between lesbian and bisexual women (all p>0.05).
DISCUSSION
Almost one-third of young adult lesbian and bisexual women in our study had not received a Pap test in the past 3 years, which is much higher than what a recent study showed for all US women of comparable ages (16%).[29] Our finding therefore adds to the growing body of evidence of cervical cancer screening disparities among lesbian and bisexual women.[15,17,20,21] Many of the correlates of Pap testing identified among women in our study do, however, mirror those among US women as a whole. We observed lower levels of recent Pap testing among Hispanic women and higher levels among women who were older, reported more lifetime sexual partners, had health insurance, and had received other preventive care in the past year.[30,31]
Recent Pap testing was less common among lesbian women compared to bisexual women, which is similar to past studies.[15,17] There are several potential contributing factors for this finding, including lesbians lacking knowledge about screening, utilizing healthcare service less frequently, and having no health insurance.[17,19,32,33] Relationships and communication between lesbian women and their healthcare providers also likely play an important role in determining whether they receive Pap tests. Indeed, women in our study, regardless of sexual identity (lesbian or bisexual), who had disclosed their sexual orientation to their healthcare provider had greater odds of having a recent Pap test.[34] It may be that women who disclose their orientation are more comfortable with, have greater trust in, and communicate more effectively with their healthcare providers, which in turn makes it more likely that these women will receive recommended care (e.g., Pap testing). Thus, it is key that healthcare providers do not make assumptions regarding women’s sexual orientation and that efforts are made to promote environments in which patients are comfortable communicating this information to their providers.
About one in five women reported that cost was the main reason they had not received a Pap test in the last three years and insuring oneself was a correlate of recent Pap testing in multivariable analyses. These findings are important since lesbian and bisexual women are less likely than heterosexual women to have health insurance coverage.[35] Increased insurance coverage due to the Affordable Care Act (ACA) may help women access routine preventive healthcare,[36] and, thus, provide more opportunities for Pap testing among lesbian and bisexual women. However, to increase cervical cancer screening, it will also be necessary for future interventions to educate both lesbian and bisexual women and healthcare providers about the importance of screening for this population and address other reasons why some women are not receiving Pap tests. For example, lesbian and bisexual women may benefit from targeted education about the need for screening in the absence of health problems and strategies that could decrease potential embarrassment, such as HPV self-testing in the privacy of their own homes.
Just over half of women in our study were willing to use an HPV self-test at home. To our knowledge, this provides the first insight into lesbian and bisexual women’s acceptability of HPV self-testing. Our finding is similar to those of past studies showing many US women are willing to use an HPV self-test at home.[8–10] From a public health standpoint, HPV self-testing at home may be particularly important for lesbian and bisexual women since they utilize sexual and reproductive health services (including Pap testing) less frequently than heterosexual women.[15,17,20,21] Given the potentially increasing role of HPV testing in cervical cancer screening,[5] future research should further explore the possibility of HPV self-testing for lesbian and bisexual women, especially those that have not had a recent cervical cancer screening test. One potential strategy for reaching this population may be an internet-based HPV self-testing program, which has been successful in promoting self-testing for other STIs.[37] Future research should also examine how HPV self-testing may affect subsequent Pap testing and receipt of follow-up care (e.g., colposcopy), since it will be critical that women who complete HPV self-tests also engage in these other behaviors.
Consistent with past studies,[38–40] some of the most common concerns about using an HPV self-test at home were using the test incorrectly, test accuracy, perceived pain associated with performing the test, and not wanting to return a completed test through the mail. We believe many of these concerns can be addressed by future interventions to promote HPV self-testing at home. For example, materials sent with HPV self-tests can include clear and easy-to-understand instructions for using the self-test device, discuss the accuracy of HPV self-testing, and alleviate concerns about self-tests being painful and returning the device through the mail. Materials should also provide information about HPV infection and HPV-related disease among lesbian and bisexual women. Providing this targeted information may increase women’s level of worry about getting an HPV-related disease, which was positively associated with willingness to use an HPV self-test at home among women in our study. Thus, materials sent with HPV self-tests that address common concerns and target modifiable beliefs may offer a low-cost and sustainable strategy that should be explored by future HPV self-testing programs.
Study strengths include a national sample of lesbian and bisexual women and the inclusion of a wide range of potential correlates. Limitations include self-reported Pap testing behaviors, which may be subject to recall bias. Our study included women who self-identified as lesbian or bisexual, which may not include all women who have sex with women. Our analyses examined women ages 21–26, and HPV testing is currently recommended as a cervical cancer screening “cotest” for women ages 30–65.[4] However, the FDA recently approved an HPV test as a primary cervical cancer screening option for women starting at age 25,[5] suggesting that HPV testing may become a screening option for younger women in the future. Women’s willingness to do a self-test at home may overstate self-testing in practice as intentions do not always translate into behavior. Additional limitations include a modest response rate and a lack of data on non-respondents.
Many lesbian and bisexual women have not received a recent Pap test despite being at risk for HPV infection and HPV-related disease. HPV self-testing at home may be a promising strategy for increasing cervical cancer screening among this population. Concerns about self-testing and modifiable beliefs associated with willingness to use an HPV self-test at home identified in this study represent targets for future efforts promoting this potential cervical cancer screening strategy.
KEY MESSAGE POINTS.
About 30% of young lesbian and bisexual women in this study had not received a recent Pap test
Over half of lesbian and bisexual women were willing to use an HPV self-test at home
Future HPV self-testing programs should address the concerns about self-testing identified by women in this study
Acknowledgments
FUNDING
Supported provided by the National Cancer Institute at the National Institutes of Health (P30CA016058).
Footnotes
LICENSE FOR PUBLICATION
I Paul L. Reiter The Corresponding Author of this article contained within the original manuscript (which includes without limitation any diagrams photographs, other illustrative material, video, film or any other material howsoever submitted by any of the contributor(s) at any time and related to this article), has the right to grant on behalf of all authors and does grant on behalf of all authors, a full copyright assignment to the Faculty of Sexual and Reproductive Healthcare as set out in the copyright assignment at: https://urldefense.proofpoint.com/v1/url?u=http://jfprhc.bmj.com/site/about/licence.pdf&k=ux7ohqYFcw1oDo0gOpSLlw%3D%3D%0A&r=%2F%2BogV40mUiztxD2ZoglBU3A9UYk2DFMc7SqKL75aQho%3D%0A&m=3gz7hHtawf2vT6E6eu6oOSSzN%2FMSybMl2WjVe5Wa40Y%3D%0A&s=8bcf0d35609fb09ef22b8cda59e82db32c8cf2effb3582a9e7f2a6bb44eb39aa.
CONFLICTS OF INTEREST
PLR has received research grants from Merck Sharp & Dohme Corp. and Cervical Cancer-Free America, via an unrestricted educational grant from GlaxoSmithKline. These funds were not used to support this research study.
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