Improving Anal Cancer Screening Messages Through Interviews From Men Who Have Sex With Men

Abstract

Anal cancer disproportionately affects men who have sex with men, particularly those living with HIV, yet screening rates remain low. This mixed-methods study examined the acceptability of anal self-exams and companion exams as supplemental screening tools among 131 participants in Chicago, IL, and Houston, TX. Data were collected through surveys and interviews and analyzed using thematic and descriptive methods. Findings indicate strong support for normalizing self and companion exams, with participants emphasizing the importance of culturally tailored messaging, diverse representation, and visuals that reduce stigma and simplify information. Trusted community sources were preferred over unfamiliar or commercial entities. Participants responded positively to messaging that framed screening in a hopeful and empowering manner, highlighting the value of approachable, relatable communication. Despite limitations in generalizability, these results provide actionable guidance for designing interventions that increase awareness, address barriers, and promote anal cancer screening among high-risk populations. Integrating culturally relevant, trusted, and visually engaging messaging into public health initiatives may enhance the effectiveness of anal cancer prevention strategies.

Introduction

Anal cancer poses a significant health threat among men who have sex with men (MSM) and transgender women, particularly those living with HIV (Clifford et al., 2021; Colón-López et al., 2018; Palefsky et al., 2022). This elevated risk is driven by increased exposure to high-risk human papillomavirus (HPV) and reduced viral clearance due to HIV-related immunosuppression (Deshmukh et al., 2023; Donà et al., 2022). Incidence in the general population is approximately 2 cases per 100,000 person-years but rises to 85 per 100,000 among MSM living with HIV (Islami et al., 2017), highlighting the need for effective screening. Although there is no national consensus on anal cancer screening in the United States, professional organizations recommend screening for high-risk populations, particularly MSM living with HIV (Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents, 2024; Stier et al., 2024).

One screening method recommended is the digital anal rectal examination (DARE), a procedure in which clinicians aim to detect palpable abnormalities in the anal canal or visible lesions at the perianus (Nyitray et al., 2020; Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents, 2024; Stier et al., 2024). Studies have found DARE to be an acceptable method for anal cancer screening among MSM (Fein & Barnett, 2024; Nyitray et al., 2024; Ong et al., 2018), though its utilization remains relatively low, especially among racial and ethnic minorities (Albuquerque et al., 2021; Gillis et al., 2020; Hicks et al., 2019). Understanding barriers to uptake remains a critical research need.

Addressing potential barriers to anal cancer screening, the exploration of anal self- or companion exams (ASE/ACE) has gained attention as an additional method (Nyitray et al., 2018). Studies on anal self-exams have identified barriers similar to those found in physician-performed exams, such as lack of knowledge and the perception of the anus as a taboo area (Ong et al., 2014; Poon et al., 2018). In addition, unique barriers like physical limitations/flexibility have been noted for self-examinations (Flores et al., 2023; Ong et al., 2014; Poon et al., 2018).

Amid the broader landscape of anal cancer screening, this paper draws on data from a clinical trial of ASE/ACE conducted in Chicago and Houston, using qualitative interviews to inform a health communication plan. The goal is to translate qualitative insights into actionable communication strategies that promote ASE/ACE as accessible, acceptable screening methods for high-risk MSM (Nyitray et al., 2018; Ong et al., 2018).

This study applies three theoretical frameworks: the Health Belief Model (HBM; Rosenstock, 1974), Prospect Theory (Kahneman & Tversky, 1979), and Framing Theory (Tversky & Kahneman, 1981), with support from Fuzzy Trace Theory (Reyna & Brainerd, 1995). The HBM suggests health behavior depends on perceived susceptibility, severity, benefits, and barriers. Prospect Theory posits people weigh losses more heavily than equivalent gains, while Framing Theory highlights how message presentation influences decision-making (“90% survival” vs. “10% mortality”). Fuzzy Trace Theory emphasizes that people rely on the gist rather than detailed facts when making decisions.

These frameworks have been applied in HIV and HPV-related research among MSM. Recent studies show that HBM constructs, particularly perceived susceptibility, benefits, and barriers, predict HPV vaccination willingness, while HPV-related beliefs among MSM inform targeted communication strategies (Reiter et al., 2024; Xing et al., 2026). Experimental research further demonstrates that message framing influences health behavior, with gain and loss-framed narratives affecting medical mistrust and self-efficacy in MSM (Gifford et al., 2025).

Within ASE and ACE, previous research indicates that these theories suggest loss-frame messages, focusing on perceived susceptibility and severity, would be the most effective messaging strategy. Loss-frame messaging is a communication approach that emphasizes the negative consequences of inaction or failure to adopt a specific behavior, aiming to motivate individuals by highlighting the risks or losses they could face (Mikels et al., 2021). Furthermore, incorporating Prospect Theory, previous research suggests that tactics that employ narratives and emotional appeals, focusing on potential losses (e.g., family time, hobbies), are expected to be most effective. The purpose is to explore further the alignment between these expectations and the themes gathered through interviews.

Methods

The study themes were gathered during a clinical trial focused on evaluating the sensitivity and specificity of ASE/ACE for the early detection of invasive anal cancer among cisgender men and transgender people who have sex with men. The research was conducted in Chicago, IL, and Houston, TX, from January 2020 to December 2022. Semi-structured interviews were conducted with participants between January 2020 and October 2021, concurrently with or shortly after their initial baseline study visit. Of the 727 participants who attended the baseline visit, 131 met the criteria for qualitative interviews and participated. Ethical oversight was conducted and approved by institutional human research protection and clinical research offices.

Participants were recruited via social media, clinic referrals, in-person outreach, email, and flyers. In Houston, recruitment occurred through an LGBT+ health care clinic, while Chicago participants were primarily recruited via geosocial networking apps and flyers. Eligible participants were cisgender men or transgender individuals who have sex with men, aged ≥25, residing in Chicago or Houston, without current anal cancer, hemorrhoids, or condyloma, and no DARE within the past 3 months. Participants not planning to move within 6 months were also eligible. The age cutoff was selected to capture adults at increasing risk prior to the recommended screening age (≥35 years; National Institutes of Health Office of AIDS Research [NIH OAR], 2024).

The qualitative interview took place at the end of the baseline visit. Beforehand, participants completed a pre-survey, received education on anal cancer and anatomy, and learned how to perform ASE/ACE, emphasizing that abnormalities did not necessarily indicate cancer. After an HCP-conducted exam, participants performed ASE or ACE privately, alone or with a partner. Interviews explored reactions to ASE/ACE results, anxiety, resource needs for at-home exams, and suggestions for improving training. Initially conducted in person, interviews later shifted online due to COVID-19. Participants received $50 for completing both the clinical assessment (Nyitray et al., 2024) and interview, which lasted 15–20 minutes on average.

To assess concordance, ASE/ACE results were compared with HCP-performed DARE findings, classified as normal or abnormal. Abnormalities were defined by palpated or visible irregularities. Participants who identified undetected abnormalities were labeled false positives, while those who missed HCP-detected abnormalities were false negatives. True positives and negatives reflected agreement with the HCP’s assessment. Interviews included all false negatives, false positives, true positives, and a random 5% of true negatives.

Data were analyzed using inductive content analysis (Elo & Kyngäs, 2008) to explore participants’ reactions, exam perceptions, and barriers. Using ATLAS.ti, transcripts were coded in stages, including open coding, category grouping, and theme development, to identify key findings.

Results

Participants’ demographic data were published by Flores et al. (2023). The 131 participants had a mean age of 49.9 years (SD = 12.7), and all identified as cisgender men. The age distribution was as follows: 39 participants (29.8%) were between 25 and 40 years old, 66 participants (50.4%) were between 41 and 60 years old, and 26 participants (19.9%) were 61 years or older. Regarding race and ethnicity, 72 participants (54.9%) identified as Non-Hispanic White, 29 participants (22.1%) as Non-Hispanic Black, 26 participants (19.9%) as Hispanic/Latino, 3 participants (2.3%) as Asian, and 1 participant (0.8%) as Other. The majority of participants identified as gay (121 participants, 92.4%), followed by 8 participants (6.1%) who identified as bisexual, and 2 participants (1.5%) who identified as queer. Notably, all participants recruited in Houston identified as gay. When considering HIV status, 58 participants (44.6%) were living with HIV, while 73 participants (55.7%) were not. There was missing data for one participant regarding HIV status. One hundred twenty-one (93.8%) participants were insured, and 8 (6.1%) were uninsured. Participants were from Chicago (66, 50.4%) and Houston (65, 49.6%). Seven themes emerged from the qualitative analysis.

Raising Awareness of the Elevated Risk of Anal Cancer Among MSM and the Importance of Conveying this Risk Sensitively and Seriously

While anal cancer risk is primarily driven by behaviors such as receptive anal intercourse and HPV exposure, participants often described this risk using identity-based language (e.g., “gay” or “homosexual”), reflecting how individuals interpret and communicate health risk.

In interviews, participants reflected on the elevated risk of anal cancer among MSM, often describing this risk in terms of being gay men. One participant expressed,

“Knowing that as a gay man, there’s a propensity, a higher propensity to have anal cancer, then that would make me be more apt to seek out information to learn what I can do to help try to prevent it.” – Age 61+, White, Non-Hispanic, Chicago

Another participant voiced a similar thought,

“I mean, just put the information out there that depending on what group you’re in, me being homosexual, it’s a higher risk. We’re in the higher risk for it. So just cater, not catering to it, but more advertising to that group of people because they need to know about it, you know?” – Age 25 to 40, Hispanic, Chicago

Participants acknowledged the need for delicate messaging to convey the seriousness of the risk without causing unnecessary fear. A participant highlighted this delicate balance, stating,

“If you want people to take it seriously, then you have to kind of impress upon them that this is something that is serious, and if you are a gay male who does practice anal sex, you are at risk, you know . . . you don’t want to scare people unnecessarily, but at the same time, you should let them know that this isn’t just some kind of study that the university is doing. This is something that has and does affect a lot of people, and if you’re a gay male who practices anal sex, you are at risk.” – Age 41 to 60, Asian, Non-Hispanic, Chicago

Participants framed risk in terms of sexual identity rather than behavior, suggesting identity-based messaging may be more salient even when risk is behaviorally driven.

Normalizing Self-Examinations and Preventive Health Care Measures for Early Detection and Awareness of Health Issues

Participants drew parallels to breast cancer campaigns, advocating for normalized anal self-exams and early detection, with one noting the importance of consulting a provider if issues arise. Another participant echoed this sentiment, emphasizing that the messaging should be “explicit as can be” in an advertisement to convey the importance of self-examination, which “could definitely save their lives.” They explained,

“I guess almost like sometimes you would see . . . breast cancer or breast self-examinations, you know, how they go about doing that. So I will look at it in that same way.” – Age 41–60, Black, Non-Hispanic, Chicago

Both participants viewed accessible, preventive messaging as vital for encouraging proactive health behaviors.

The encouragement for individuals to perform self-checks during routine activities, like showering, was noted. Participants emphasized the importance of conversations to normalize self-checking as a straightforward and convenient way to identify potential health issues. One participant highlighted,

“So, if we have conversations to normalize that, you know, checking yourself is an easy and convenient way, and if you have a problem, you need to deal with it.” – Age 41 to 61, White, Non-Hispanic, Houston

This approach encourages self-examination as a routine part of health care, aiming to detect potential issues early, such as guidance on testicular health.

Promoting Anal Cancer Awareness Through Survivor Testimonials and Personal Stories From the Community

Participants highlighted the power of survivor testimonials and personal stories in raising awareness about anal cancer. One participant suggested,

“It would probably be nice to find somebody who was diagnosed with it and was treated, and it sort of would serve as an ambassador for anal cancer survival because it also shows that . . . It’s very powerful to see.” – Age 25 to 40, White, Non-Hispanic, Houston

The notion of survivor ambassadors was emphasized, providing a positive narrative for those diagnosed with anal cancer. Survivor testimonials also conveyed a positive outlook, emphasizing that an anal cancer diagnosis does not necessarily equate to a death sentence. Participants acknowledged that early detection can lead to favorable outcomes, with one participant stating,

“With prevention, if they got early detection, could end with a positive outcome. So I mean, just hearing any number that means that there’s less deaths or less cases that reach stage four is all I would need to hear.” – Age 41 to 60, Black, Non-Hispanic, Houston

This perspective aimed to counteract potential fears associated with anal cancer. Participants recommended featuring relatable ambassadors from diverse backgrounds to make the messaging more impactful. One participant suggested involving people who looked like them, stating,

“I like looking on—at the TV when they have the PrEP and the HIV medicine and people that look like myself or people that are similar to myself, and you have these messages, and they’re out there. And so something like that, basically just something that—you know, someone that looks like us, that are just talking about the issues and basically going out there and get tested . . . ‘If you see something, say something,’ type there. So I like that type of marketing, advertising.” – Age 25 to 40, Black, Non-Hispanic, Chicago

Diversity in testimonials aimed to resonate with a broader audience and establish a sense of connection and shared experiences.

Enhancing Anal Cancer Awareness Through Creative and Accessible Educational Tools

Participants recognized the potential of shower cards as a creative, accessible educational tool for self-examination. One participant highlighted the natural setting of the shower, stating,

“I think that you’re naked in the shower, and it’s a convenient time rather than just saying out of your day, okay, now I’m going to go and give myself a self-examination. Being in the shower is kind of a real natural situation to be in that would make the examination easy.” – Age 61+, Hispanic, Houston

This approach aimed to reduce barriers by integrating the examination into a natural routine.

The use of animated images and cartoons has emerged as a favored approach for educational tools. Participants emphasized that animated images and cartoons effectively conveyed sensitive health information. One participant described how animated depictions could capture viewers’ attention while simplifying complex topics. He noted that he had seen an online animation by a graphic artist demonstrating how to perform a proper douche. This animated sequence, he explained, was “clever, smart, modern, and kind of funny” and effectively illustrated the process step by step, including potential consequences if done incorrectly. Such a lighthearted, informative approach, he suggested, would be engaging and could encourage others to adopt new practices with confidence. Another participant affirmed this thought by saying,

“I think the little cartoon, comical side of it would help out. Like, it could potentially stand out in a darker setting like a club or a bar. But, I thought that the little pamphlet though, that was . . . like it’s how it was designed. It gave you the information you needed to know, to the point, and you knew right away what it was about. It had some deep, training information.” – Age 25 to 40, Hispanic, Houston

The engaging and culturally ambiguous nature of animated visuals was highlighted, contributing to reduced anxiety and increased attention. In addition to using animation, participants recommended a comprehensive outreach approach, including the creation and distribution of cartoon-style posters and web ads on targeted social media platforms to present both positive and negative aspects to motivate.

The Need for Increased Marketing and Outreach Efforts in Medical Settings and Gay Community Media to Raise Awareness of Anal Cancer

Participants emphasized the need for increased marketing efforts within medical settings, particularly in physicians’ offices for male health. One participant highlighted the lack of representation in family clinics, stating,

“It’ll have to be more so in those male physicians’ offices. I don’t know. I don’t know. Like in a family clinic, you have so many different images that are around. They don’t really get into men’s health or stuff like that.” – Age 25 to 40, Black, Non-Hispanic, Chicago

This insight underlined the importance of tailoring messages to specific medical settings to address the men’s health awareness gap. Within physicians’ offices, participants recommended having informational brochures or pamphlets about anal cancer.

Participants also recommended targeted outreach in gay community media, including online platforms, LGBTQ publications, and community spaces such as the [LGBTQ Community Center]. Two participants outlined potential channels:

“Probably definitely in the gay media, like [LGBTQ Newspaper]. I would put it online. And I would have information. . .you know, like postcards or flyers or things like that, like at the [LGBTQ Community Center], that sort of thing. Maybe even have it. . .have some sort of information in the bars.” – Age 61+, Black, Non-Hispanic, Houston

“I think ads like that could go on things like [Gay Dating App] and [LGBTQ Dating App] and maybe in [LGBTQ News Publication] or in. . .I can’t think of the other magazine I used to get, but in any of the print media that would work.” – Age 61+, White, Non-Hispanic, Chicago

These suggestions highlighted the importance of reaching the gay community through familiar and frequented spaces.

Leveraging Community and Trusted Sources for Effective Outreach and Education on Anal Cancer Awareness

Participants preferred information from trusted community organizations and agencies. One noted, “I’m just thinking that if it was an ad or kind of like a PSA that was put out by someone, or an agency I was familiar with, I would probably be much more receptive” – Age 41 to 60, White, Non-Hispanic, Houston. This highlights the importance of establishing trust through partnerships with reputable organizations and placing ads in local LGBTQ+ media. Another participant emphasized the same point, discouraging messages from pharmaceutical companies and similar sources, stating,

“Some type of agency other than a drug company. Whether it be federal, state, whatever local . . . even Department of Health or whatever, just . . . even if it’s physicians . . . or I don’t know how to describe it, but just something that’s coming more targeted from the community that’s not commercialized.” – Age 41 to 60, White, Non-Hispanic, Houston

This insight highlighted the perceived authenticity and credibility of messages not associated with commercial interests.

Participants discussed the effectiveness of word of mouth within friend groups. One shared the experience of promoting anal cancer awareness with friends, stating,

“I put it in my friend group, and I’m in multiple friends groups. I put the plug in there, like, ‘This is something that I’m going to do. You all should do it.’ . . . Some of my friends signed up. Some were like, Okay, I’m going to wait for you to go first.” – Age 41 to 60, Black, Non-Hispanic, Chicago

This underscored the role of personal recommendations within trusted social circles.

The Importance of Credibility and Trust in Medical Institutions and Health Care Providers for Receiving Health Information

Participants emphasized the importance of accreditation and validation from reputable sources, expressing greater confidence in information from familiar organizations and health care providers. One shared,

“To me, any health care ad would have to come through, for instance, my physician or one of my physicians.” – Age 41 to 60, White, Non-Hispanic, Houston.

Trust and familiarity with health care providers were key to judging the credibility of health information.

Participants filtered out information from untrusted sources. A participant shared feeling overwhelmed by health ads and emphasized trust in deciding which to engage with, stating,

“In my line of work, the amount of health ads, insurance . . . the things that I get . . . probably would boggle your mind. But it gets to the point where scroll, delete, scroll, delete, scroll, delete, right? I don’t even pay any attention to them.” – Age 41 to 60, White, Non-Hispanic, Houston

This highlights how trust shapes participants’ filtering of relevant and credible health content.

Discussion

Participants preferred messaging from recognizable, reputable sources, including visuals and cartoons that convey clear, gist-based information, consistent with prior research (Nitkowski et al., 2024). They also favored avoiding fear-based tactics, instead emphasizing risks of not screening alongside benefits of early detection (Gallagher & Updegraff, 2012). Importantly, these findings highlight a distinction between behaviorally driven risk and identity-based perceptions of risk. While anal cancer risk is associated with behaviors such as HPV exposure and receptive anal intercourse, participants often framed risk in terms of sexual identity, which may influence how messages are interpreted. These preferences reflect reliance on simplified, gist-based information and framing, consistent with Fuzzy Trace Theory and Framing Theory.

Participants shared that using narrative and emotional appeal within a culturally relevant context is a powerful tactic for increasing perceived susceptibility, severity, and benefits, aligning with behavior change research. Conversely, many participants discussed the need for the normalization of ASE and ACE and a focus on the treatability of anal cancer if positive. Although this finding differs from expectations based on Prospect Theory, it offers valuable guidance for a health communication campaign. Rather than emphasizing loss aversion and negative consequences, messages that balance risk with positive, emotionally resonant narratives were favored. Focusing on normalization and treatability of anal cancer suggests that culturally relevant, hopeful messaging may better promote behavior change.

Key Findings and Interpretation

Need for Tailored Health Communication

Participants emphasized the need for culturally relevant messages to increase salience, particularly among high-risk groups. Their preference for messaging that highlights the risks of not screening, alongside the benefits of early detection, reflects principles of Prospect Theory (Kahneman & Tversky, 1979), which suggests that individuals weigh potential losses more heavily than gains. These perspectives also align with constructs of the Health Belief Model (Rosenstock, 1974), as participants described perceived susceptibility, severity, and barriers such as stigma, fear, and access as influencing screening behaviors. These findings highlight the importance of identifying such barriers to inform tailored communication strategies.

Normalization of Screenings

Participants’ calls to normalize anal cancer screening highlight the importance of framing screening as routine and socially accepted. Their emphasis on integrating self-examinations into everyday activities, such as showering, aligns with Fuzzy Trace Theory (Reyna & Brainerd, 1995), which posits that individuals rely on simple, gist-based representations when making health decisions. These findings also align with Framing Theory (Tversky & Kahneman, 1981), as participants emphasized that presenting screening as routine may reduce stigma and discomfort.

Creative and Visual Health Communication Tools

Participants’ preference for visual communication supports Fuzzy Trace Theory (Reyna, 2021), as simplifying complex information into clear, memorable concepts may enhance understanding and retention. Visuals and animations were described as effective tools for conveying sensitive health information, reducing fear and stigma, and normalizing screening behaviors. These preferences also align with elements of the Health Belief Model (Rosenstock, 1974), particularly in enhancing self-efficacy and reducing perceived barriers by making screening more approachable.

Limitations

This study has several limitations that may have influenced its results. Participant bias is possible, as most were asymptomatic community members rather than clinical referrals. Although 45% of interviewees identified as non-white, this may not represent sexual minority men in broader metro areas. Short interview lengths may have restricted deeper discussion of ASE/ACE barriers. Future research should explore subgroup differences, including racial and positional preferences, to improve tailored health messaging. Creating affirming and inclusive clinical environments may also foster greater trust (Aronson et al., 2013). Finally, the focus on cisgender men limits generalizability to transgender and gender-diverse individuals. Broader demographic inclusion will strengthen representativeness and enhance the relevance of health communication for at-risk populations.

Implications for Research and Practice

This study highlights the importance of collaborating with trusted community partners and organizations to enhance the reach, engagement, and cultural relevance of health communication. Findings support the use of gain- and loss-framed messaging, along with engaging visuals, to promote ASE for anal cancer screening, consistent with prior research (Gallagher & Updegraff, 2012). Grounded in Prospect Theory, Framing Theory, and the Health Belief Model, these results provide insight into strategies to increase anal cancer awareness and screening among MSM, including those living with HIV. Future research should examine the effectiveness, sustainability, and cultural relevance of these approaches, as well as how collaboration across researchers, public health practitioners, and community organizations can support inclusive prevention and early detection efforts.