Cervical cancer is one of the few tumours medicine can stop before it appears, and cytology — the Pap test — is the tool that makes it possible. But screening only works if it reaches everyone who needs it, and that is where a well-documented gap appears. A meta-analysis published in the journal International Journal of Gynecological Cancer pools 21 observational studies and compares what happens to transgender and gender diverse people with a cervix against cisgender women.
The main result is a clear difference in access. Transgender and gender diverse people have less than half the odds of being up to date with cervical cancer screening (odds ratio 0.53; 95% confidence interval 0.35–0.79). The finding holds whether the data come from what participants report themselves or from medical records, which strengthens it. The studies included range from 116 to 238,036 participants or Pap tests and come from very different health systems.
The second finding is more technical but has very concrete consequences. Among transgender and gender diverse people, the odds of an unsatisfactory cytology — a sample the laboratory cannot read reliably — are more than nine times higher (odds ratio 9.92; 95% confidence interval 7.42–13.26). The most frequent cause is epithelial atrophy, which testosterone can induce, together with the difficulty of a sampling procedure that many people find uncomfortable or dysphoric. An unreadable cytology does not mean more cancer: it means repeating the test, delaying diagnosis and adding anxiety and cost.
Precision matters here, because a quick reading of the numbers can mislead. When the authors analysed abnormal cytology results, they found no overall difference between the two groups (odds ratio 0.75; 95% confidence interval 0.37–1.49). In studies that did not specify testosterone use, or that used all-comer cisgender comparators, transgender people actually showed lower odds of abnormal cytology (0.44). The core problem, then, is not more disease: it is a screening system that fits these bodies poorly and produces lower-quality tests and poorer follow-up.
The barriers behind this are known and largely avoidable. Screening invitations go to whoever is registered as a woman, so many transgender people are never called. Pelvic examination can be uncomfortable or outright dysphoric, and not every clinician feels trained to care for these patients. The result is a chain of small obstacles that, added together, explain why part of the population with a cervix misses out on effective screening.
The authors flag the limitations of this kind of work. These are observational, heterogeneous studies, with different ways of measuring screening and classifying testosterone use, and they cannot establish cause and effect. Still, the pattern repeats consistently enough to point to a problem of health service organisation, not a problem of the people themselves.
That is why the paper points to structural solutions: screening guidelines based on anatomy rather than registry identity, protocols that recognise the particularities of tissue under hormone treatment and, above all, evaluation of alternatives such as self-sampling and primary human papillomavirus (HPV) testing. These strategies have already improved coverage in other populations and avoid the examination many people skip precisely because of dysphoria. The question the meta-analysis leaves behind is not whether these people need screening — they need it just as anyone with a cervix does — but how often the system itself shuts them out of the easiest route to getting it.
Source: Cervical cancer screening among transgender and gender diverse individuals: a systematic review and meta-analysis. Srajer A, Hutchinson JM, Metcalfe A, Brenner DR, Black KA, Mattatall F, Nicolau I, Ronksley PE. International Journal of Gynecological Cancer 2026;36:104850. DOI: 10.1016/j.ijgc.2026.104850.
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