Advancing equity: the urgent need to include trans and gender diverse people in cervical cancer prevention in Australia

The right to safe, equitable, and timely health care is recognised as a fundamental human right.1 Despite this, trans and gender diverse people face significant barriers to accessing safe, appropriate, and inclusive health care tailored to their specific needs, including cancer prevention and follow‐up services.2,3 The federal government's 2023 National strategy for the elimination of cervical cancer in Australia recognises the disparities faced by trans and gender diverse people, and identifies cervical cancer as a preventable disease of inequity.4 The strategy further recognises trans and gender diverse people as a population at risk of being left behind in the government's aim to “achieve equitable elimination of cervical cancer as a public health problem by 2035”, and a priority population requiring a targeted approach.

We position ourselves as a diverse team of researchers, clinicians, and people who use health care committed to equitable health. In this work, we bring a range of perspectives, which includes trans and gender diverse, LGBTQ+ (lesbian, gay, bisexual, transgender, queer, and other diverse sexualities and genders), Aboriginal, Torres Strait Islander, racial minority, and neurodivergent researchers. Our team has decades of relevant expertise, as reflected in our research, clinical practice, and importantly, our lived experience. We draw from our individual and collective expertise to highlight current issues and challenges, and advocate for improved access to cervical cancer prevention for trans and gender diverse people to work toward equitable elimination of cervical cancer.

What we know

Cervical cancer is now “almost entirely a disease of inequity; without systematically addressing inequities, Australia will not achieve elimination”.4 It is estimated that at least 2–3% (between 64 000 and 96 000) of young people are trans and gender diverse in Australia,5,6 who will continue to experience poorer health outcomes without systemic change and investment to address barriers in human papillomavirus (HPV)‐related cancer prevention care.

Trans and gender diverse people experience heightened exposure to cancer and cervical cancer‐related risk factors (such as smoking)7,8,9 and disproportionate cancer‐related burden compared with the general population.9,10 Trans and gender diverse people with a cervix have equivalent rates of cancer‐causing HPV as cis women, yet are recognised as a group at risk of being under‐represented across the three pillars required to meet the national strategy elimination targets: (i) HPV vaccination,11 (ii) routine cervical screening and treatment for pre‐cancers2,12 and (iii) early access to treatment and care.2,6

One national study found that only around half of trans and gender diverse participants reported having received the HPV‐preventive vaccination (47.0%, aged 18–24 years; 52.2%, aged 25–34 years).2 In another study, almost half (48%) of eligible trans and gender diverse participants with a cervix reported that they had never participated in cervical screening,12 compared with 32%13 of the general population. Of those who had screened, 27.5% reported receiving an abnormal result.12 Inequitable barriers experienced by trans and gender diverse people contribute to delays in health care provision, increasing the risk of later‐stage diagnosis and treatment (see Box). Despite clear inequities, there is insufficient evidence, data, and research that is inclusive and representative of trans and gender diverse people in Australia. As such, it is often necessary to rely on broader LGBTQ+ literature, or research with LGBQ women regarding cervical cancer prevention, despite trans and gender diverse people having unique barriers and needs.

What we still do not know

The extent of cancer‐related harms and unwarranted clinical variation related to cancer for trans and gender diverse people remain unknown due to cis‐normative systemic data collection approaches, which omit diversity in gender and sexuality.25 In lieu of such data, there is limited knowledge of cervical screening, cervical cancer incidence and mortality, and treatment of precancerous or cancerous lesions for trans and gender diverse people in Australia. To the best of our knowledge, there has been no focused research on trans and gender diverse peoples’ experiences on self‐collection cervical screening since it was offered universally in Australia, or the acceptability of resources, materials and promotion strategies.

Now is the time to prioritise equitable inclusion for trans and gender diverse people in cervical cancer prevention

In 2022, the National Cervical Screening Program eligibility criteria were expanded to offer all people with a cervix access to self‐collection cervical screening tests (a lower vaginal swab for HPV), which could improve uptake by eliminating the need for specimen collection by a health professional. This approach provides an opportunity for increased uptake by trans and gender diverse people by removing some of the discomfort experienced during collection of samples by clinicians.26 However, barriers remain; cervical screening, even by self‐collection, must predominantly be accessed through a health provider.27 This requirement may limit uptake for trans and gender diverse people who do not have a health provider who they trust and who is knowledgeable on trans and gender diverse health, or knows they are a trans person with a cervix in the first place. Further, offer of self‐collection is reliant on health provider knowledge of both self‐collection approaches, and trans and gender diverse specific needs. Although trans and gender diverse people were not specifically mentioned in the 2021 study conducted before the eligibility expansion of self‐collection in Australia, the study reported that “a third of clinicians did not believe that self‐collection was a reasonable alternative to practitioner‐collected screening for under‐screened women”.28 This is contrary to international evidence indicating that self‐collection can increase uptake among otherwise under‐screened populations, including trans and gender diverse people,26,29 highlighting the need for training in this space and updated research to understand if clinician perceptions have changed since the eligibility expansion of self‐collection.

Promisingly, there has been an increase in inclusive and targeted awareness campaigns for cervical cancer prevention for LGBTQ+ people, which include trans and gender diverse representation in promotion,30 such as the “Can We” platform in New South Wales and the national “Own It” campaign.31 Free cervical screening with self‐collection options have been available at LGBTQ+ community events and festivals in 2025 as part of these initiatives.30 Access to such mobile screening and ongoing removal of barriers at mainstream health services have potential to help improve screening uptake for trans and gender diverse people; however, it is critical that resources are tailored specifically for trans and gender diverse people, and not exclusively cisgender women.

The national HPV school‐based vaccination program has been active since 2007; however, it was restricted to “female” (as relative to presumed sex characteristics) students aged 12–13 years until 2013, when eligibility was expanded to include all, irrespective of sex or gender. Those who missed the school vaccination program can currently “catch up for free up to age 26”.32 Despite the risk of lower uptake of the vaccination for LGBTQ+ people during the school‐based program,11,14,16 limited routine data collection means there is a lack of evidence on how to best target populations in need of the vaccine through catch‐up approaches, and the true magnitude of people who are vaccinated or unvaccinated.

Moving forward

To address these discrepancies and meet the national target of elimination, there is a clear need for the following.

Representation in health data collection

Trans and gender diverse people and their gender identity are not being captured in national health data, limiting our understanding of the magnitude of health disparities experienced by this population. These data are crucial for identifying key areas of improvement and should align with the National Health and Medical Research Council Statement on sex, gender, variations of sex characteristics and sexual orientation in health and medical research.33

Investment into translational research

We need future research to build on existing national studies that highlight the needs and barriers to screening,2,12 to include the trans and gender diverse people's awareness, acceptance, uptake, or experiences with self‐collection and relevant promotion materials since the national rollout. Further, this would provide an opportunity for the consideration of intersectional factors to develop a more targeted approach across priority populations.

Comprehensive training for health providers on trans and gender diverse people and their needs34

Training should extend to support staff, such as medical receptionists, to improve the safety of health services. Health provider knowledge and understanding of trans and gender diverse people's specific needs (ie, reminders, appropriate pronouns, offers of self‐collection), and a safe environment, are critical to providing accessible prevention and follow‐up care, such as sensitive screening and colposcopy approaches. This should be embedded in university curriculums.

Investment to establish, expand and sustain awareness campaigns

Campaigns developed to specifically target LGBTQ+ people through inclusive representation and appropriate language14,35 must be adequately supported, with investment in research on improving reach (ie, knowledge about screening registries, regional and rural considerations, differences across metropolitan suburbs). Investment for a targeted approach in addition to these broader LGBTQ+ campaigns is warranted to ensure the unique needs and preferences of trans and gender diverse people are met.

Community‐led initiatives to ensure safe, inclusive materials and approaches

We support calls for targeted inclusion in materials and resources for cancer prevention services and promotion informed and designed for and by trans and gender diverse people. This includes strategies to ensure safe notifications from national registries,36 and targeted materials (ie, the “How to collect your own sample” card).

Inclusivity and targeted approaches to catch‐up programs

A catch‐up approach to achieve equity in delivery of the HPV vaccine for LGBTQ+ and other high risk populations4 has been identified as a national priority. We recommend a targeted and tailored catch‐up strategy for school‐aged people who may be trans and gender diverse, and also for young adults who have left school but are still eligible for free vaccination.

Recognition of diversity within trans and gender diverse people and communities

There is a critical lack of research in Australia that explores the multifaceted diversity within these populations, particularly for those who experience multiple forms of marginalisation, such as people outside of major cities, Aboriginal and Torres Strait Islander people, people with a disability, and people who are neurodivergent. Targeted investment in research should inform targeted campaigns that consider different priority factors in line with the national strategy targets.4

Conclusion

Recent national cervical cancer prevention programs and advancements in key technologies provide a timely opportunity to address barriers to screening uptake and improve health outcomes for trans and gender diverse people.4 Cervical cancer is now considered a preventable disease, with Australia aiming to eliminate cervical cancer as a public health problem by 2035,37 in line with global38 and national strategies.4 As detailed in the national strategy,4 this goal relies on equitable access to HPV vaccination, cervical screening, and access to treatment for all people. Equitable elimination can only be achieved through the provision of safe, targeted, and tailored prevention care and adequate representation in national data to improve widespread uptake of HPV vaccination and cervical screening for trans and gender diverse people.