Sex of Sexual Partners and Human Papillomavirus Vaccination Among U.S. Girls and Women

Sexual Orientation-Related Disparities in Neonatal Outcomes

OBJECTIVE

To evaluate whether disparities exist in adverse neonatal outcomes among the offspring of lesbian, gay, bisexual, and other sexually minoritized (LGB+) birthing people.

METHODS

We used longitudinal data from 1995 to 2017 from the Nurses' Health Study II, a cohort of nurses across the United States. We restricted analyses to those who reported live births (N=70,642) in the 2001 or 2009 lifetime pregnancy questionnaires. Participants were asked about sexual orientation identity (current and past) and same-sex attractions and partners. We examined preterm birth, low birth weight, and macrosomia among 1) completely heterosexual; 2) heterosexual with past same-sex attractions, partners, or identity; 3) mostly heterosexual; 4) bisexual; and 5) lesbian or gay participants. We used log-binomial models to estimate risk ratios for each outcome and weighted generalized estimating equations to account for multiple pregnancies per person over time and informative cluster sizes.

RESULTS

Compared with completely heterosexual participants, offspring born to parents in all LGB+ groups combined (groups 2-5) had higher estimated risks of preterm birth (risk ratio 1.22, 95% CI, 1.15-1.30) and low birth weight (1.27, 95% CI, 1.15-1.40) but not macrosomia (0.98, 95% CI, 0.94-1.02). In the subgroup analysis, risk ratios were statistically significant for heterosexual participants with past same-sex attractions, partners, or identity (preterm birth 1.25, 95% CI, 1.13-1.37; low birth weight 1.32, 95% CI, 1.18-1.47). Risk ratios were elevated but not statistically significant for lesbian or gay participants (preterm birth 1.37, 95% CI, 0.98-1.93; low birth weight 1.46, 95% CI, 0.96-2.21) and bisexual participants (preterm birth 1.29, 95% CI, 0.85-1.93; low birth weight 1.24, 95% CI, 0.74-2.08).

CONCLUSION

The offspring of LGB+ birthing people experience adverse neonatal outcomes, specifically preterm birth and low birth weight. These findings highlight the need to better understand health risks, social inequities, and health care experiences that drive these adverse outcomes.

Associations Between Risk Perception and HPV Knowledge and Vaccine Uptake: Highlighting the LGBTQ+ Population

INTRODUCTION

Gay and bisexual males and other LGBTQ+ communities are more frequently exposed to factors associated with an increased risk of human papillomavirus (HPV) acquisition. Vaccination is critical to protect against HPV+ head and neck cancer (HNC). We characterized the association of perceived level of risk of contraction with HPV knowledge, and vaccine decision-making.

STUDY DESIGN

Cross-sectional cohort.

SETTING

LGBTQ and general survey Reddit forums (control).

METHODS

A survey was shared amongst the online forums. Descriptive statistics characterized the data. Multivariable logistic regression was used to understand factors associated with vaccination, self-perceived high risk, and knowledge of HPV + HNC.

RESULTS

Of 718 respondents, most were female (41.09%), Caucasian (59.89%), college-educated (33.01%), and insured (77.15%) with a mean age of 30.75 years. Half were vaccinated (49.16%), with most unvaccinated endorsing interest (60.58%). Few dependents were vaccinated (25.91%), with interest in vaccination among parents of unvaccinated children (38.58%). Knowledge of HIV's association with HPV (62.95%), HPV causing HNC (55.57%), and the vaccine's efficacy against HNC (55.57%) was also moderate. Identifying female (P = .042), a self-perceived high-risk (P < .001), and having vaccinated children (P < .001) increased vaccination likelihood; transgender (P = .021), or lesbian or gay sexual identity (P < .001) decreased likelihood. Personal HNC diagnosis (P < .001), self-vaccination (P < .001), having vaccinated children (P < .001), having anal sex (P = .001) or no knowledge of past HPV status (P < .001) increased likelihood of high self-perceived risk.

CONCLUSION

Efforts to improve public education regarding the association between HPV and HNC and vaccination efficacy are required to better inform vaccine decision-making among individuals at risk for HPV infection.

Human Papillomavirus Vaccination Among Transgender and Gender Diverse People in the United States: An Integrative Review

Objective

This integrative review explores the barriers to and facilitators for human papillomavirus (HPV) vaccination among adult transgender and gender diverse (TGD) people in the United States.

Data Source

A systematic search of electronic databases included PubMed/MEDLINE, CINAHL, and EMBASE from 1985 to 2020.

Inclusion and Exclusion Criteria

Inclusion criteria included studies from the United States that described HPV vaccination barriers or facilitators and included adult TGD participants, both quantitative and qualitative studies. Exclusion criteria were studies that reported only HPV vaccine prevalence, non-English/non-U.S. studies, and studies limited to pediatric populations.

Data Extraction

Two investigators used Covidence software to screen studies and manage data extraction. Quality of the quantitative studies was appraised using a checklist proposed by the Joanna Briggs Institute (JBI); qualitative studies were appraised using quality criteria informed by the literature.

Data Synthesis

The Social Ecological Model guided the review to organize barriers to and facilitators for HPV vaccination at the patient-, provider-, and system-levels.

Results

Database searches and hand-searching yielded 843 citations. After screening, eight articles were retained in the review. Seven were cross-sectional studies and one was a qualitative focus-group. All retained quantitative studies met six of the eight JBI quality checklist items.

Conclusion

The low proportion of TGD participants in the retained studies highlights a gap in knowledge about HPV vaccination among this population. Future studies of HPV vaccination should recruit TGD people to better represent their perspectives.

Disparities in human papillomavirus (HPV) vaccine initiation and completion based on sexual orientation among women in the United States

OBJECTIVES

We compared HPV vaccine initiation and completion of heterosexual with lesbian and bisexual (LB) women.

METHODS

We aggregated National Health and Nutrition Examination Survey data from 2009 to 2016 for 3,017 women aged 18 to 34 y in the United States. HPV vaccine initiation was defined as reported receipt of ≥1 dose of the vaccine and completion as receipt of the three recommended doses. Weighted percentages and multivariable logistic regression models were used to examine differences in HPV vaccine initiation and completion between heterosexual and LB women.

RESULTS

Approximately 12% of respondents self-identified as LB women. Overall, a higher percentage of respondents (26%) had initiated the HPV vaccine than completed the three vaccine doses (17%). In the bivariate analysis, LB women had higher initiation ([35% of LB women versus 25% heterosexual]; p = .0012) and completion rates ([24% of LB women versus 17% heterosexual]; p = .0052) than heterosexual women. After adjusting for covariates, compared to heterosexual women, LB women were 60% (aOR = 1.60, 95% CI: 1.16-2.19) more likely to initiate and 63% (aOR = 1.63, 95% CI: 1.12-2.37) more likely to complete the HPV vaccine.

CONCLUSIONS

Although LB women had higher likelihood of HPV vaccine initiation and completion compared with heterosexual women, their HPV vaccine uptake was well below the Healthy People 2020 target (80%). Understanding differences in the drivers of vaccine uptake in the LB population may inform strategies that would further increase HPV vaccine uptake toward achieving the 80% completion target.

Human Papillomavirus Vaccines: An Updated Review

Human papillomavirus (HPV) vaccines, which were introduced in many countries in the past decade, have shown promising results in decreasing HPV infection and related diseases, such as warts and precancerous lesions. In this review, we present the updated information about current HPV vaccines, focusing on vaccine coverage and efficacy. In addition, pan-gender vaccination and current clinical trials are also discussed. Currently, more efforts should be put into increasing the vaccine’s coverage, especially in low- and middle-income countries. Provision of education on HPV and vaccination is one of the most important methods to achieve this. Vaccines that target HPV types not included in current vaccines are the next stage in vaccine development. In the future, all HPV-related cancers, such as head and neck cancer, and anal cancer, should be tracked and evaluated, especially in countries that have introduced pan-gender vaccination programs. Therapeutic vaccines, in combination with other cancer treatments, should continue to be investigated.

Sexual Orientation Differences in Cervical Cancer Prevention among a Cohort of U.S. Women

BACKGROUND

Although much has been published in recent years on differences in Papanicolaou (Pap) tests across sexual orientation, other aspects of cervical cancer prevention remain underexplored, such as human papillomavirus (HPV) vaccination, HPV co-tests, or abnormal Pap tests.

METHODS

Data came from participants (aged 24-54 years) enrolled in an ongoing, longitudinal, U.S.-based cohort study, the Nurses' Health Study 3 (N = 12,175). Analyses were restricted to participants who met the current guidelines for care (e.g., ≥21 years of age for Pap tests).

RESULTS

Mostly heterosexual women were more likely to initiate HPV vaccination than completely heterosexual women with no same-sex partners. All other comparisons across sexual orientation for HPV vaccination initiation and completion and the age of initiation were not statistically significant. Compared with completely heterosexual women with no same-sex partners, mostly heterosexual and lesbian women had lower odds of having a Pap test within the past 2 years. Completely heterosexual women with same-sex partners, mostly heterosexual women, and bisexual women had their first Pap test at an earlier age, had higher odds of having an HPV co-test, and had higher odds of having a positive HPV or abnormal Pap test compared with completely heterosexual women with no same-sex partners. In contrast, lesbian women had lower odds of having positive HPV or abnormal Pap results (odds ratio, 0.65; 95% confidence interval, 0.49-0.86) than completely heterosexual women with no same-sex partners.

CONCLUSIONS

There are significant differences across sexual orientation groups in cervical cancer prevention for Pap test timing and positive HPV and abnormal Pap tests, but few differences in HPV vaccination initiation, completion, and age at initiation. Interventions should focus on increasing routine Pap testing among mostly heterosexual and lesbian women.

Human Papillomavirus Risk Perceptions Among Young Adult Sexual Minority Cisgender Women and Nonbinary Individuals Assigned Female at Birth

CONTEXT

Some sexual minority women may be less likely than other women to engage in human papillomavirus (HPV) prevention behaviors. Although risk perceptions have been found to be associated with health behaviors, HPV risk perceptions among U.S. sexual minority women have not been examined.

METHODS

In 2016-2017, in-depth interviews were conducted in Boston with 29 sexual minority individuals aged 18-36 who were assigned female at birth (AFAB) and identified as women or nonbinary. Purposive sampling was used to recruit participants online, through community-based and student organizations, and by word of mouth. Thematic analysis was employed to examine participants' HPV risk perceptions.

RESULTS

Participants incorrectly linked HPV risk to the exchange of genital fluids, and a hierarchy of perceived risk emerged in relation to sexual orientation: Individuals who engage in penile-vaginal sex with partners who were assigned male at birth (AMAB) were perceived to be at highest risk, and lesbians and individuals with only AFAB partners were perceived to be at low risk. Lesbians and participants with only AFAB partners identified sex with bisexual women or AFAB individuals with AMAB partners as a risk factor for HPV infection. Risk perceptions were shaped by health care providers' linking HPV risk to sex with AMAB individuals, a lack of discussion of HPV with parents and peers, and the exclusion of information on HPV and sexual minority women from school-based sex education.

CONCLUSION

Interventions providing sexual minority AFAB individuals with comprehensive, accurate and tailored information about HPV risk are needed.

Sexual Orientation Disparities in Human Papillomavirus Vaccination in a Longitudinal Cohort of U.S. Males and Females

PURPOSE

This study sought to examine how human papillomavirus (HPV) vaccination may differ across sexual orientation groups (e.g., bisexuals compared to heterosexuals)-particularly in boys and men, about whom little is known.

METHODS

Data were from a prospective cohort of 10,663 U.S. females and males enrolled in the Growing Up Today Study followed from 1996 to 2014. Participants were aged 11-24 years when the vaccine was approved for females in 2006 and 14-27 years when approved for males in 2009. In addition to reporting sexual orientation identity/attractions, participants reported sex of lifetime sexual partners. Log-binominal models were used to examine HPV vaccination across sexual orientation groups.

RESULTS

Among females, 56% received ≥1 dose. In contrast, 8% of males obtained ≥1 dose; HPV vaccination initiation was especially low among completely heterosexual males. After adjusting for potential confounders, completely heterosexual (risk ratio [RR]; 95% confidence interval [CI]: 0.45 [0.30-0.68]) and mostly heterosexual (RR; 95% CI: 0.44 [0.25-0.78]) males were half as likely to have received even a single dose compared to gay males. Compared to lesbians, no differences were observed for completely heterosexual or bisexual females, but mostly heterosexual females were 20% more likely to have received at least one dose.

CONCLUSIONS

HPV vaccination rates in the U.S. are strikingly low and special attention is needed for boys and men, especially those who do not identify as gay. Vaccinating everyone, regardless of sex/gender and/or sexual orientation, will not only lower that individual's susceptibility but also decrease transmission to partners, females and/or males, to help eradicate HPV through herd immunity.

Sexual orientation identity disparities in human papillomavirus vaccination initiation and completion among young adult US women and men

PURPOSE

To examine the association between sexual orientation identity and human papillomavirus (HPV) vaccination initiation and completion among both women and men.

METHODS

Using data from the 2013 and 2014 National Health Interview Survey, we estimated logistic regression models for the association between sexual orientation identity and HPV vaccination initiation (≥1 dose) and completion (≥3 doses) among US women and men in relation to sociodemographic and healthcare factors. Analyses were restricted to individuals for whom the HPV vaccine was recommended at some point in their lives, namely women aged 18-34 years (n = 9,734) and men aged 18-31 years (n = 6,812).

RESULTS

Among all women, bisexual women had higher adjusted odds of HPV vaccination initiation [(odds ratio) 1.71; (95 % confidence interval) 1.20-2.45] and completion (1.59; 1.05-2.42) than heterosexual women. No difference was observed in the odds of HPV vaccination initiation or completion between lesbian and heterosexual women. Among women who had initiated HPV vaccination, lesbians had lower adjusted odds of completion than heterosexual women (0.41; 0.19-0.90). Among all men, gay men had higher adjusted odds of initiating (2.07; 1.17-3.52) and completing (3.90; 1.68-9.06) HPV vaccination than heterosexual men. No difference was observed in the odds of HPV vaccination initiation or completion between bisexual and heterosexual men. Among men who had initiated HPV vaccination, gay (4.36; 1.28-14.83) and bisexual (20.92; 2.34-186.73) men had higher adjusted odds of completion than heterosexual men, although these results are unreliable and should be interpreted with caution.

CONCLUSIONS

Interventions are needed to promote HPV vaccination among all US women and men, regardless of sexual orientation identity.