Cervical cancer screening among transgender and gender diverse individuals: a systematic review and meta-analysis.

Abstract

Objective: To conduct a systematic review and meta-analysis of observational studies comparing cervical cancer screening participation and Pap cytology results between transgender/gender diverse individuals and cisgender female individuals.

Methods: MEDLINE, EMBASE, and CINAHL were searched from database inception to January 7, 2026, by 2 independent reviewers. Primary observational studies reporting up-to-date cervical cancer screening and/or Pap test results in transgender/gender diverse individuals with a cervix compared with cisgender female individuals were included. Following the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines, data were independently extracted and critically appraised in duplicate.

Results: Twenty-one studies were included, with sample sizes ranging from 116 to 238,036 participants or Pap tests. Twelve studies (57.1%) assessed up-to-date screening, and 9 (42.9%) reported un-satisfactory and abnormal Pap cytology. Compared with cisgender female individuals, transgender/gender diverse individuals had significantly lower odds of being up to date on cervical cancer screening (odds ratio 0.53, 95% confidence interval 0.35 to 0.79). Estimates were similar when stratified by self-report versus medical record data. Transgender/gender diverse individuals had more than 9-fold higher odds of un-satisfactory cytology (odds ratio 9.92, 95% confidence interval 7.42 to 13.26). Overall, abnormal cytology did not differ between groups (odds ratio 0.75, 95% confidence interval 0.37 to 1.49). In stratified analyses, lower odds of abnormal cytology for transgender/gender diverse individuals were observed among studies with mixed or unspecified testosterone use (odds ratio 0.44, 95% confidence interval 0.32 to 0.60) and in studies using all-comer versus atrophic cisgender comparators (odds ratio 0.44, 95% confidence interval 0.33 to 0.59). Findings for un-satisfactory cytology did not differ significantly across these strata. There was no evidence of small-study effects.

Conclusions: Transgender/gender diverse individuals with a cervix are less likely to be up to date on cervical cancer screening and more likely to have un-satisfactory Pap cytology. Abnormal cytology appears similar overall but varies across testosterone use and comparator strata. These findings underscore the need for anatomically inclusive, evidence-based screening guidelines and evaluation of alternative approaches, such as primary human papillomavirus testing, to improve cervical cancer screening equity and effectiveness.