Screening reduces incidence of a late-stage cervical cancer diagnosis by 60%–90%. Yet, bisexual people are participate less than their heterosexual counterparts, putting them at higher risk for late-stage diagnosis. Guided by an adaptation of Quinn & Earnshaw’s Concealable Stigmatized Identity – Outcomes Model (CSI-O), this dissertation aimed to identify and investigate relationships among key determinants of cervical cancer screening participation among bisexual adults eligible for screening. With a focus on bisexual adults, three Manuscripts served to answer 4 research questions: (1) What determinants of health are associated with cancer screening participation?; (2) What is the predictive relationship between identity disclosure and mental health symptoms?; (3) What is the predictive relationship between identity disclosure and cervical cancer screening participation?; and (4) What is the predictive relationship between mental health symptoms and cervical cancer screening participation? Manuscript 1 was a systematic literature review that identified how determinants of health relate to cancer screening participation among differing stigmatized sexual identities. Gaps identified within existing literature supported priority areas of study, including (1) cancer screening contexts; (2) stigmatized sexual or gender identity groups; and (3) determinants of health affecting screening participation. Priorities identified in this systematic review were applied to the CSI-O model to support the remaining chapters. Manuscript 2 applied a secondary analysis of a broader study and examined the relationships between gender identity disclosure and mental health symptoms among people assigned female at birth who identified as bisexual and transgender. Findings supported that lower identity disclosure was associated with poorer mental health, but the association of identity disclosure with mental health depended on the disclosure setting; people who disclosed in healthcare settings, but not at home, reported higher anxiety and depressive symptoms. Additionally, identity disclosure patterns provided a comprehensive understanding of the relationships between identity disclosure and mental health. Manuscript 3 used a descriptive cross-sectional study to examine how identity disclosure and mental health predict cervical cancer screening participation among bisexual adults. Broadening the findings from the secondary analysis (Manuscript 2), the sample included bisexual adults, either cisgender or transgender. Findings suggested that identity disclosure was associated with cervical cancer screening participation among bisexual people, but associations were dependent on how identity disclosure was measured, and the cervical cancer screening participation outcome considered. Identity disclosure pattern was significantly associated with cervical cancer screening participation, and individuals who disclosed identity at their last cervical cancer screening were more likely to be up-to-date. However, level of identity disclosure in an individual setting was not associated with any cervical cancer screening participation outcome. Compared to those who reported no fear of stigma in healthcare, those who reported having fear were significantly less intent to screen. Research: Key relationships were identified in the adapted CSI-O model: identity disclosure and mental health symptoms predict behavioral outcomes, and identity disclosure predicts mental health. Strong statistical methods were employed in this study, including multiple regression, which supported the predictive relationships outlined in the adapted CSI-O model; however, they do not confirm causality. Practice: Past difficulty receiving healthcare due to stigmatized gender identity was related to poor mental health, and fear of stigma in healthcare was related to lower intention to screen. To prevent negative outcomes, providers should maintain affirming care environments for bisexual people. Policy: To support unique care needs of stigmatized groups, creative solutions are needed to replace previously available government funding. At-home testing kits are available for cervical cancer self-screening, and should be more widely available to support increased participation for bisexual people. Conclusion: This dissertation is the first step towards understanding unique needs of bisexual people in cancer screening. Bisexual-specific factors for cervical cancer screening participation are identified, and findings provide a pathway toward individualized care for at-risk groups.
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