Lesbian, gay, bisexual and transgender (LGBT) cancer patients (and those who love them) experience extra challenges after diagnosis and continuing many years post treatment. There is research to show that LGBT cancer survivors report lower satisfaction with their cancer care than heterosexual survivors and these differences extend to their quality of life following treatment. Lesbian and bisexual cancer survivors are over twice as likely to report fair or poor health post treatment, compared to heterosexual female survivors. Gay, bisexual and transgender men have more psychological distress after surviving cancer than their heterosexual and cisgender peers. These studies are published but not well known, reflecting the invisibility of LGBT people within the healthcare system. Last week, a huge change occurred in LGBT visibility and a professional commitment to address these health disparities: the American Society of Clinical Oncologists (ASCO) released a position paper, calling out the impact of discrimination on LGBT people in society and within the healthcare system. More important than simply listing the additional difficulties LGBT cancer survivors face, the position paper recommends multiple actions that will correct the problems, with a focus on those that oncologists can take the lead in bringing about. ASCO Issues Recommendations for Reducing Cancer Disparities among Sexual and Gender Minority Populations
LGBT people carry a disproportionate cancer burden. Most of the increased risks can be traced to the discrimination and stigma experienced as a result of living as sexual and gender minorities in this country. To deal with that stress many LGBT people engage in behaviors that raise their cancer risks. For example, bullying has been shown to dramatically increase the odds of tobacco use, the largest preventable cause of cancer. Today, LGBT people use tobacco at rates that are 63% higher than the general population. In addition, LGBT people use (and abuse) alcohol at much higher rates, increasing their risk for head and neck, esophageal, and breast cancers. In lesbian and bisexual women, we also see higher than average rates for obesity, coupled with a lower likelihood of having a biological child before age 30, both of which increase breast cancer risk. Gay and bisexual men have anal cancer rates that are 44 times the national average, due to exceptionally high rates of infection with HPV. ASCO has publicly recognized these increased risks and recommends increased cancer education efforts targeted to this population.
The response to increased risks should be stricter adherence to routine healthcare visits and screening, but LGBT people experience multiple barriers to such care. As a group, LGBT people are less likely to have health insurance and many have experienced previous discrimination at their doctor’s office or hospital, making them reluctant to seek preventive or screening care. This is especially true for transgender people. Many hospitals do not have policies that protect against further discrimination. The barriers to routine care result in LGBT people being more likely to be diagnosed with more advanced cancers. ASCO has publicly acknowledged these barriers LGBT people face in getting the highest quality care and offers concrete steps for providing more welcoming environments to LGBT patients, including a request for a “coordinated effort across national groups” to address this.
One of the largest obstacles LGBT patients face is finding culturally competent oncology providers, across disciplines, who have been adequately trained in communicating with this population, welcoming LGBT families-of-choice into treatment, and respectfully asking about sexual orientation and gender identities. When LGBT people can bring their entire selves into treatment, they fare better. In other words, those who are out to their providers have better self-reported health than those who feel they must remain closeted to receive unbiased care. ASCO recognized the damage caused by an uneducated workforce and offers recommendation to increase cultural competence in the workforce, as well as fostering a more welcoming work environment for LGBT cancer providers.
The ASCO position paper goes even further. LGBT health disparities are not just the result of individual actions, by either patients and/or providers. Broad policy changes are also needed, including laws that would ban discrimination and ensure adequate healthcare coverage for all people, including the LGBT community. Finally, ASCO calls for increased research on this population. Until information is solicited and recorded on sexual orientation and gender identity, LGBT people will remain invisible and underserved.
The more LGBT people with cancer and those at risk are seen and respected, the better our health outcomes will be. ASCO is leading the way in enumerating the personal, social, and policy changes that need to be made for LGBT people.
(posted originally in Cancer Knowledge Network, 4/11/17