Toolkit for engaging Under-screened and Never-screened women in the National Cervical Screening Program

Barriers to screening
Engagement strategies
Case study video
Healthcare provider resources
Healthcare provider training
Consumer resources

LGBTI people experience higher rates of discrimination and poorer health outcomes than other Australian women, and may be less likely to participate in regular cervical screening than heterosexual women. This is particularly the case for women who have never had sex with men.

Transgender men who still have a cervix are also at risk of cervical cancer. They are less likely to have regular cervical screening than the general population, and more likely to have an unsatisfactory result. They are also less likely to be offered screening by healthcare providers.

Barriers to screening

In addition to the general barriers women may face in participating in cervical screening, the following barriers have been identified as common for women who identify as lesbian, bisexual or are same-sex attracted, and people who identify as transgender and have a cervix.

Barriers to cervical screening forLGBTI people

• Misconception that lesbian, bisexual and same-sex attracted women, and transgender men who have a cervix, are not at risk of cervical cancer (i.e. belief that cervical screening is not necessary)
• Healthcare providers’ misconception that lesbian, bisexual and same-sex attracted women, and transgender men who have a cervix are not at risk of cervical cancer (i.e. incorrectly advising patients not to participate in screening)
• Misconception that HPV is only spread through heterosexual intercourse (i.e. incorrect belief that women who have not had sex with men are not at risk of cervical cancer)
• Discrimination and social stigma
• Fear of negative attitudes of healthcare providers
• High levels of psychological distress, experiences of trauma and abuse
• Healthcare providers’ lack of understanding about sexual and gender diversity
• Heterosexual assumptions by healthcare providers
• Difficulty finding a suitable healthcare provider (i.e. accepting, empathetic, non-judgemental)
• Previous negative experiences with healthcare providers/healthcare services
• Reluctance to disclose sexual orientation/identity
• Potential distress for transgender patients caused by the conflict between their sex assigned at birth (i.e. female) and their gender identify (i.e. male)
• Transgender men with a cervix may find speculum examinations painful.

Engagement strategies

The following evidence-based strategies have been shown to be effective in engaging women who identify as LGBTI and have a cervix in cervical screening.

Strategy	Detail
Staff training	Encourage all health service staff to undertake Lesbian, Gay, Bisexual, Transgender, and Intersex (LGBTI) -specific cultural sensitivity training.
Appropriate communication	When discussing cervical screening with patients, healthcare provider should employ a nonjudgmental and open-minded approach (e.g. avoiding the assumption that everyone is heterosexual). Use terminology that encompasses all sexual orientations (e.g., asking about a patient’s partner/significant other instead of their husband), and acknowledging the patient’s same-sex partner and including them in conversations. Advise lesbian, bisexual and same-sex attracted women, and transgender men who have a cervix, that they are at risk of cervical cancer and recommend that screening is appropriate for them. When communicating with patients, reflect their use of language and self-identification. If in doubt, ask what terms they prefer. Use gender neutral language on intake forms and give patients ample choices when documenting next of kin, relationship status and sexual orientation.
Avoid making assumptions	If a female patient identifies a female partner, do not assume that she has never had a male sexual partner or been pregnant.
Supportive environment	Provide a safe, supportive, sensitive and welcoming environment for the LGBTI community. Make the waiting room welcoming with posters and resources directed to the LGBTI  community Prominently display your health service’s policy of non-discrimination and confidentiality. Signal your health service’s willingness to provide quality services to all patients and your openness to disclosures about sexuality e.g. through messages on your website.

Case study video

Healthcare provider resources

• Guide to sensitive care of lesbian, gay and bisexual people attending general practice – This guide has been designed to assist GPs, practice nurses and practice staff to be inclusive of and sensitive to LGBTQI people. It includes definitions for minority sexual orientations and the specific health issues faced by LGB people, as well as a range of suggestions for improving communication and practice. (4 pages) – The University of Melbourne

Healthcare provider training

Various training programs are available to assist healthcare providers working with LGBTI communities to improve their practice:

• LGBTI Professional Development, Education and Training – information on training opportunities available across Australia – National LGBTI Health Alliance
• Victoria - HOW2 create a lesbian, gay, bisexual, transgender and intersex (LGBTI) inclusive service – interactive training program with 4 x 4.5 hour sessions held 6-8 weeks apart. Conducted by Gay and Lesbian Health Victoria (GLHV).

Consumer resources

• 5. Consumer resources – includes a range of downloadable resources about to support conversations about cervical screening