Our study demonstrates that sexual minority adolescent and young adult women underutilize routine reproductive health screenings including Pap smears and STI tests. Both lifetime and past-year Pap testing as well as history of STI diagnosis varied by sexual orientation. After accounting for sociodemographics and sexual history, mostly heterosexual/bisexual females were less likely than heterosexual females to have had a Pap test in the past year but more likely to have ever had an STI. Lesbians were far less likely to receive Pap test screening than completely heterosexuals, even when accounting for sociodemographics and sexual history.
Prior studies document that sexual minority youth do not have as much support from family and heterosexual peers around sexuality issues[26
] and they do not believe they are at risk for abnormal Pap tests and STI diagnoses due to their sexual orientation,[27
] which might lead to lower rates of sexual health screenings like Pap smears and STI tests. Less social support,[26
] lower risk perceptions,[27
] or an initial adverse experience like a clinician assuming a particular sexual orientation which is also linked to poorer reproductive health outcomes[13
] could lead to infrequent care and higher abnormal Pap test and HPV diagnoses rates. All of these mechanisms should be explored in future research. Clinicians should understand these barriers and communicate to patients that certain sexual behaviors, regardless of sexual orientation identity, increase risk. Our finding that mostly heterosexual/bisexual females had higher odds of being diagnosed with an STI, compared to completely heterosexuals, is consistent with previous findings in adults.[11
] No sexual orientation differences were observed in the odds of receiving an HPV diagnosis, but there were few reported cases. HPV DNA is present in almost all invasive carcinomas and the vast majority of abnormal Pap test results.[28
] However, more than double the number of participants who reported an HPV diagnosis reported an abnormal Pap test, suggesting that participants may have a poor understanding of the meaning and cause of an abnormal Pap test. The lower rates of even routine physical exams use in sexual minorities compared to completely heterosexuals underscore how important it is to encourage sexual minority adolescent girls and young women to regularly seek care.
Lesbian adolescents and young adults had lower odds of having a Pap smear, both over their lifetime and in the past year. Again, possible factors contributing to this disparity include a lower risk perception,[29
] poor patient-provider communication,[10
] lack of insurance,[13
] or other health care system factors.[30
] Regardless of a patient's reported sexual orientation identity, clinicians must offer a Pap test to every individual who meets age guidelines. Lesbians may be less likely to use birth control and therefore miss regular health care opportunities. Future studies with greater statistical power may reveal that lesbians have lower odds of abnormal Pap tests and STI diagnosis, but examining comparisons across sexual orientation groups will continue to be difficult even in large studies because of care underutilization by lesbians, since cervical dysplasia and most STIs are asymptomatic and will not be detected without regular preventative care. Previous studies report that lesbian adolescents[11
] and adults[19
] are at an increased risk for STIs but are unlikely to report receiving a diagnosis.[33
Although our study had numerous strengths like the large, national sample, there were limitations. While we were able to examine a younger population compared to prior studies, we were limited by the homogenous racial/ethnic composition of our cohort and by the fact that all of the participants are children of nurses. Daughters of nurses may have higher health care utilization than the general population, which would overestimate utilization in this sample. Therefore, the sample is not representative of US adolescents and young adults. All of the data were available only from self-reports rather than another source such as medical records. One of the limitations of self-reports in this context is that any gynecological exam could be misreported as a Pap test, which could lead to over-reporting. Due to working with existing data, we could not access any other information such as more detailed sexual history variables. Additionally, our data likely underestimate the true prevalence of our outcomes because many abnormal results, like an asymptomatic STI, go undetected and previous research indicates that adolescent and young adult women do not reliably report detected diagnoses like HPV infections.[34
] Restricting the analysis to 2005 Pap guidelines did not appear to bias the results when we reanalyzed the data using current guidelines in the sensitivity analyses. However, the new Pap test guidelines may impact reproductive health screenings among sexual minorities. Now that eligibility is based on age rather than a combination of age and sexual history, sexual minority woman may have more similar care to their heterosexual peers. More research is needed to explore these associations. Lastly, we had low power to detect differences in some outcomes such as abnormal Pap tests and HPV diagnoses. Another important strength of our study is that while previous research has varied the operational definition of “lesbian,”[10
] often combining behavior and identity measures or even including bisexual women in this category, we were able to more precisely examine different sexual orientation identity groups by distinguishing between lesbian and bisexual women and controlling for sexual history.
Regular Pap tests and STI screenings are needed by all young adult females who meet current guidelines, regardless of sexual orientation. Despite changes in Pap test guidelines, STI screenings recommendations have remained consistent. The new Pap test recommendations, which suggest screening begin at age 21 regardless of sexual history, should make it easier for providers to determine those in need of screening. Even when we restricted our analysis to women aged 21 years and older, most of the sexual orientation group disparities remained. Providers and health educators should be aware of these disparities so that they can provide appropriate care to young women and their families and ensure that all young women receive reproductive health screening. Many adolescents and young adults encounter barriers to HPV and STI screening such as care site access problems (geography and hours), privacy concerns, and fear of disclosing stigmatized or risky sexual behavior.[30
] Sexual minority youth may be further deterred especially in settings perceived as insensitive to their specific concerns. Further research is needed to explore reasons sexual minority females are not accessing care as recommended since this may suggest opportunities to improve reproductive health screenings as well as broader health care access issues.