Training essential to understand cancer risks, address barriers facing LGBTQ individuals

Lesbian, gay, bisexual, transgender or queer individuals, or sexual and gender minorities, have been shown to have a disproportionate risk for cancer.

Between 3% and 12% of the U.S. population, or 11 million people, are LGBTQ, and it is estimated that over 1 million are living with cancer.

However, the CDC’s National Program for Cancer Registries, NCI’s SEER program and the National Cancer Database do not routinely collect sexual orientation or gender identification (SOGI) cancer surveillance public health information. Therefore, limited national data exist for these populations.

In light of this lack of data, APPs should familiarize themselves with the cancer risks faced by the LGBTQ population and the cancer screening barriers they often experience.

‘Disparate health care’

Ongoing research has revealed overall disparate health care of LGBTQ populations.

In the U.S., numerous reasons for health care disparities have been studied, including discrimination by health care providers in up to 70% of health care visits. Further, studies have shown 15% of LGBTQ individuals have fear of accessing health care outside of their community, 13% have been denied health care based on their SOGI status, 22% of transgender individuals need health care but are unable to afford it, and one out of five transgender individuals is refused care based on their gender status.

Increased rates of depression, substance abuse, physical activity limitations, obesity, mental distress, fear, discrimination and self-reported fair-to-poorer health status all lead to poor health outcomes in LGBTQ populations.

In addition to these inequalities, a growing body of research shows LGBTQ disparities in cancer care. Due to discrimination and stigma, LGBTQ populations have high rates of risky behaviors that are known contributors to cancer, are less likely to seek routine cancer screening and may present with advanced stages of cancer. Studies with small-to-moderate numbers of participants have shown LGBTQ populations, compared with non-LGBTQ populations, have higher rates of tobacco and alcohol misuse, both of which contribute to risk for cancer.

In sexual minority (SM) populations, 68% of individuals have a chance of developing lung cancer and are at greater risk for developing breast cancer. In particular, SM males have a 3.5% increased risk for skin cancer, and the rate of anal cancer in SM males is 30 times higher than that of heterosexual males.

As overall cancer mortality rates continue to decrease, people are living longer with cancer as a chronic condition. Unfortunately, this is not the case for sexual and gender minority (SGM) individuals, who are less likely to participate in cancer screening, have higher rates of certain cancers and who present for health care later in the cancer trajectory, which may lead to higher mortality rates.

As a result of these disparate statistics, it becomes more evident that APPs should ask all patients about their sexual orientation and conduct organ inventories to ensure appropriate education about screening and prevention can be achieved. For example, it is known that lesbian and bisexual women have higher rates of alcohol and tobacco use, obesity with higher-fat diets and nulliparity, all factors that place these populations at higher risk for cancer development. When APPs conduct thorough histories that include SOGI status, targeted prevention strategies can be provided. APPs should be aware of the intersectional and multilayered risks for cancer among racial and ethnically diverse LGBTQ populations.

Barriers to cancer screening

It is well-established that early initiation of cancer treatment leads to improved outcomes and increased survival.

SGM populations are at increased risk for development of anal, breast, cervical, colorectal, endometrial, lung and prostate cancers. Although cancer screening can reduce breast, cervical, colorectal, prostate and lung cancer mortality, data suggest LGBTQ individuals eligible for screening do not routinely participate.

Compared with heterosexual women, lesbians are less likely to present for routine mammography; gender monitories (GMs) and bisexual women are less likely to present for breast, cervical and colon cancer screening; gender nonconforming (GNC) individuals are less likely to have discussions about prostate screening tests with their providers; and GMs are less likely to participate in overall cancer screening tests.

Barriers to cancer screening participation in these populations include:

• prohibited gender identity and expression or being bisexual;
• racial and ethnic minority status;
• varying degrees of educational attainment;
• financial insecurity;
• lack of knowledge among both SGMs and health care providers;
• nondisclosure of SOGI status to health care providers;
• overall poor psychological distress/coping;
• feelings of gender dysphoria;
• social isolation;
• lack of cultural competency;
• lack of trust and fear of discrimination;
• low health engagement;
• heteronormative assumptions by health care providers or unwelcoming environments; and
• lack of national screening guidelines.

Facilitators for cancer screening participation include older age; matched ethnicity/race among patients and their health care providers; life experiences; willingness; prior sexual activity history or abnormal Pap; having insurance, a higher income and employment; higher educational attainment; familial history of cancer; cultural competency; positive communication and teamwork; knowledge of screening guidelines; welcoming environments with partner inclusion; and legal protections.

The identification of barriers and facilitators can serve as an impetus to further explore cancer screening characteristics of SGMs within larger data samples. As opposed to gender-based cancer screening, APPs can collect an organ inventory so they can accurately recommend guidelines for screening of the uterus, ovaries, cervix, prostate and breasts.

With LGBTQ-specific education about cancer screening, APPs can be better equipped to provide appropriate education. Currently it is recommended that transgender women who have received hormone replacement therapy for more than 5 years and transgender men who still have breasts undergo the same mammography screening as cisgendered women. It is important to ask which organs the transgender individual has in a sensitive, accepting and safe manner to establish a trusting relationship between patient and provider.

Need for funding, education

It is necessary to understand that SGMs are a disparate population — a fact that is essential for allotment of additional funding for research, health care provider education and targeted interventions.

Having funding earmarked for SGM populations can lead to improved cancer care for them. For example, educational programs targeting the specific needs of SGM populations can provide health care providers the necessary tools to exhibit cultural sensitivity and create an open environment for SOGI status disclosure and subsequent exploration of the appropriate cancer screening for patients.

APPs can seek out educational opportunities specific to SGM populations through online free learning resources, like the Safe Zone Project, and be knowledgeable of and sensitive to their own biases. They also should utilize inclusive language and avoid cisgendered and heteronormative assumptions.

Practitioners can create welcoming environments for SGM populations by utilizing magazines and photographs of same-sex couples, nonbinary persons and transgender persons of varied ethnic and cultural backgrounds. In addition, practitioners can provide education to front-line administrative staff utilizing nongendered pronouns such as “ma’am” or “sir” to instead use the patient’s preferred name.

These populations will only grow in the future, and health care providers need to be given the training to meet the needs of SGM populations so that they are more likely to seek health care without fear and will have improved health outcomes.

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