Cytology and LGBT+ health: establishing inclusive cancer screening programs

Abstract

There are substantial disparities in cancer screening for sexual minorities and gender non-conforming patients. In additional to patients having trauma due to negative experiences with the healthcare system, disparities may be heightened due to heteronormative and cisnormative design of screening programs and electronic medical record systems. Furthermore, there are morphologic challenges specific to certain specimen types from the LGBT + population, such as anal cytology samples, cervical cytology from transgender men taking testosterone, and neovaginal cytology samples. Men who have sex with men are at increased risk for anal cancer compared with the general population. While early detection of anal dysplasia decreases the risk of invasive carcinoma, screening programs are not widespread. Cervical cancer screening may be psychologically and physically challenging for transgender men and non-binary patients. The use of exogenous testosterone therapy causes atrophic changes in cervical cytology samples which mimic high-grade dysplasia. The rate of unsatisfactory samples are also increased in this population. Although HPV driven cancers have been reported in patients with neovaginas, there are currently no guidelines about appropriate screening for transgender women and intersex patients who have neovaginas. Cytopathologists can optimize the health of LGBT + patients in many ways including advocating for inclusive screening guidelines, validating self-collection for HPV and cytology samples, updating requisition forms to better capture the spectrum of gender expression, and recognizing the morphologic changes in cytology samples due to exogenous hormone use.

Keywords: Anal cytology; Cancer screening; Cervical cytology; Equity; HPV; Transgender health.

Figure 1

Features found in benign cervical samples with testosterone related atrophy include (A) transitional cell metaplasia, characterized by powdery chromatin and longitudinal nuclear grooves and (B) clusters of small cells, as seen in Tamoxifen therapy. In high grade dysplasia (C) the nuclei are dark with coarse, clumped chromatin (ThinPrep, Papanicolaou Stain, 40×).

Figure 2

Features found in neovaginal samples include (A) abundant inflammation and degenerated intestinal epithelial cells in an intestinal graft, (B) well-preserved glandular cells in a sigmoid graft, (C) hyperkeratosis in a skin graft, and (D) well-preserved squamous cells in a dilator-created neovagina (ThinPrep, Papanicolaou stain, 40×).