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Cervical cancer is the most common cancer in women aged 35 and under, with around 3,000 women diagnosed each year in the UK. Despite this, just 72 per cent of eligible women in England attend cervical screening (or smear) tests, which can help to detect abnormal cells early, and prevent around 75 per cent of cervical cancers from developing.
In the LGBT+ community however, the figures are much lower still. According to Lawrie Roberts, Macmillan LGBT and Cancer Programme Co-ordinator at the LGBT Foundation, around half (51 per cent) of eligible women who have sex with women have never attended a smear test.
A large part of this is down to the persistent misconception that only women who have sex with men are at risk of cervical cancer.
"As a lesbian I've been given zero specific cervical screening advice. I've always assumed you either get it because you've got a genetic predisposition for certain cervical problems – but none of my female family members have been affected – or you come into contact with certain men's dicks, which I don't!" says 30-year-old Sophie.
"I do go when I'm invited, because it's only every three years. I don't resent going exactly, but I always think there's really, really not that much need for me to go along," she adds. "It sounds awful but I feel like inviting me is a waste of time and resources."
But in fact, as Roberts says, "we now know that anyone with a cervix, regardless of your sexual orientation or gender identity, will need to have a smear, and NHS guidance changed to reflect this in 2009."
What causes cervical cancer?
Virtually all cervical cancers (99.7 per cent) are caused by the human papillomavirus (HPV). HPV is so common that it affects four out of five of us at some point in our lives, although in most cases it's cleared up by the immune system without any lasting damage. In rare cases, though, if the virus persists, it can cause cervical abnormalities, which could, in turn, develop into cancer if not treated early enough.
Although HPV is more easily transmitted through heterosexual intercourse, it is passed on through bodily fluids, so oral sex, transferring vaginal fluids on hands and fingers, or sharing sex toys all put you at risk. The virus can also be carried, without any symptoms, for a number of years, so lesbian and bisexual women who have previously had sex with a man, or whose partner has previously had sex with a man, may also have been exposed to HPV without realising.
Indeed, studies suggest that between 3 and 30 per cent of lesbian and bisexual women test positive for HPV. Lesbian and bisexual women are also more likely than heterosexual women to be current or former smokers, which, according to Public Health England, is another risk factor for cervical cancer. Having a mother or sister affected by cervical cancer also slightly increases your risk. However, we're not sure if there really is any genetic element or whether factors such as people being more likely to smoke if other close family members do, for instance, accounts for it.
39-year-old Sarah is bisexual and in a civil partnership with a woman. She's more acutely aware of the risks than many, after a friend's ex-girlfriend recently died from cervical cancer.
"This is such an important subject for lesbian and bi women; there's so much misinformation out there," she says. "I was told by a female doctor, when I explained that I was in a relationship with a woman but wanted a smear, 'Oh, nuns don't get cervical cancer'. Seriously!"
The problem also extends to other members of the LGBT+ community. Half of eligible transgender men and non-binary people with a cervix have never attended a cervical screening test. Trans men who are registered with their GP as male are not routinely invited for cervical screening tests, but Public Health England recommends that any trans man aged 25-64 who still has a cervix should consider going for a smear.
Understandably, cervical screening can be particularly distressing for those affected by gender dysphoria, so Robert Music, Chief Executive of Jo's Cervical Cancer Trust, says: "It's important that messages about the importance of the test do reach trans men, and that they are supported to attend."
For Ellie*, who is asexual but has romantic relationships with women, there are similarly complex reasons for not attending her smear tests.
"I don't know if it's unrelated to not wanting to be touched by a partner, but I don't like the idea of being probed by a doctor when I can't even let a partner touch me," she explains. "I feel the same about breast examinations or having tests on my heart, because I don't really like my boobs being touched."
So what are the solutions? "With non-attendance for screening likely to put people at risk, we would like to see more of a drive to making the screening process inclusive of and inviting to LGBT communities," Roberts says.
"It's important to consider a range of approaches to do this, from LGBT awareness training for staff, to targeted campaigns and the adaption of wording in recall letters to speak directly to LGBT communities about the importance of attendance," he adds.
Another idea, which Ellie would like to see introduced, is a method for self-sampling rather than having to endure a speculum examination from a nurse or GP. Jo's Cervical Cancer Trust would also like to see this option explored as part of the NHS cervical screening programme, Music adds, as another possible means of overcoming the sometimes complex barriers to attendance.
All woman aged 25-64, who have a cervix, are eligible for cervical screening and will be invited for smear tests every three to five years. Although they aren't routinely invited, trans men can request a smear test at their GP surgery, or specialist trans clinics like CliniQ at 56 Dean Street in Soho.
*Name has been changed