Colorectal Cancer Screening Status Among Transgender and Cisgender Individuals in Safety Net Primary Care Settings

Context: As screening is key to early colorectal cancer (CRC) identification and treatment, disparate screening rates drive known inequities in CRC morbidity and mortality in the overall U.S. population. We investigated CRC screening rates in transgender and cisgender individuals in the community health center (CHC) population.

Objective: To compare CRC screening rates by gender identity in primary care safety net CHC populations, as CHCs often provide primary care to the transgender population, which has high poverty rates.

Study Design and Analysis: Retrospective cohort analysis; adjusted Poisson regression used to compare rates of up to date (UTD) CRC screening between cisgender (referent) and transgender patients.

Setting or Dataset: Electronic health record (EHR) data for 2014-2019 from a national network of 620 individual CHCs sharing an EHR.

Population Studied: Patients aged 50-75 years with >1 office visit at a study clinic in the study period, with gender identify status documented in the EHR.

Outcome Measures: Percentage of study period months for which a given patient was up to date on CRC screening, as defined by national guidelines.

Results: Of 579,438 patients, 0.12% were documented as transgender, 61% as cisgender, 38% had no documentation, and 0.8% declined to provide gender identity. Regression results showed that rate of months UTD for CRC screening were similar between documented transgender vs. cisgender persons (adjusted RR 0.95, 95% CI 0.82-1.09); UTD rates were also higher among female (vs. male), gay or lesbian (vs. heterosexual), Hispanic (vs. non-Hispanic white), and white (vs. non-Hispanic Black) persons, and among persons with an assigned primary care provider (vs. none), private insurance or Medicare (vs. Medicaid), and higher income (vs. lower).

Conclusions: Contrary to research conducted in other settings, we found no statistically significant differences in rates of CRC screening by gender identity in CHCs. As CHCs may reduce barriers to CRC screening access barriers for transgender patients, future research should assess how to disseminate CHCs’ strategies for doing so as a means to mitigate national disparities in CRC screening. Analyses included patients with documented gender identity; results may not be generalizable to a broader population. Two out of five patients did not have documented gender identity; research is needed to address barriers to systematic EHR documentation of gender identity.