A new study examining the health-care needs of lesbian, gay, bisexual, and transgender/transsexual patients has found myriad disparities in access to cancer care.1 The researchers reviewed nearly 170 papers published over the past 15 years on the health-care needs among this population. Although the majority of studies focused on family systems, human immunodeficiency virus/acquired immunodeficiency syndrome prevention and maintenance, and overall health, there have been limited efforts to systematically identify and address disparities in care across the cancer continuum, including prevention strategies, early detection, diagnosis, treatment, survivorship, and end-of-life care.
To understand the impact of cancer on this medically underserved population, the researchers concentrated their efforts on seven cancer types that may disproportionately affect lesbian, gay, bisexual, and transgender/transsexual patients, including anal, breast, cervical, colorectal, endometrial, lung, and prostate cancers. Their findings showed significant disparities in both income and health-care equality and in medical outcomes compared with heterosexuals and are highlighted here:
Lesbian, gay, bisexual, and transgender/transsexual individuals tend to have lower incomes, which impact their ability to access health insurance, and are less satisfied with their standard of living than heterosexuals.
Health and utilization of health-care services among lesbian, gay, bisexual, and transgender/transsexual individuals are adversely affected by marginalization; and about 30% of lesbian, gay, bisexual, and transgender/transsexual adults do not seek health-care services or lack a regular health-care provider compared with 10% of heterosexual adults.
Lesbian, gay, bisexual, and transgender/transsexual individuals experience significant barriers to accessing health care due to health insurance costs, fear of stigmatization, and a lack of trust in the physician-patient relationship—Patients fear they may receive substandard care or risk a breech in confidentiality if they disclose their sexual orientation or gender identity.
Members of some lesbian, gay, bisexual, and transgender/transsexual subgroups have a higher incidence and mortality rates of certain cancers, including a higher incidence of anal cancer in men, lung cancer in both men and women, and breast and cervical cancers in lesbian and bisexual women.
Implementing local, state, federal, and institutional policies that include lesbian, gay, bisexual, and transgender/transsexual populations; improving the mechanism for lesbian, gay, bisexual, and transgender/transsexual–related research, such as collecting and analyzing gender identity and sexual orientation data in cancer clinical trials; and including sexual orientation and gender identity questions on national population surveys and registries, such as the Surveillance, Epidemiology, and End Results (SEER) Program cancer registries, will help identify the demographics and disparities of this population and reveal gaps in cancer care, according to Matthew B. Schabath, PhD, senior author of the Cancer and Lesbian, Gay, Bisexual, Transgender/Transsexual, and Queer/Questioning populations study.
According to the latest estimates from the Centers for Disease Control and Prevention,2 3.4% of the population in the United States identifies as lesbian, gay, bisexual, and transgender/transsexual. Other studies put the number between 3% and 12%.3
The ASCO Post talked with Dr. Schabath, Assistant Member of the Cancer Epidemiology Program at Moffitt Cancer Center in Tampa, Florida, about his research findings; why lesbian, gay, bisexual, and transgender/transsexual individuals may be at greater risk for certain cancers; and how to reduce health disparities and improve cancer care for this patient population.
Research Obstacles
What were your biggest obstacles in researching the cancer health disparities in the lesbian, gay, bisexual, and transgender/transsexual population?
In our study, we reference nearly 170 papers on the health of sexual minorities, but we reviewed close to 500 studies to get the 170 that we used. The most staggering problem we found is that the amount of research on sexual minorities is sparse, and the data in local or national databases are not well captured.
A Population at Risk
Your study found higher incidences of certain cancer types, including anal, lung, breast, and cervical cancers, in the lesbian, gay, bisexual, and transgender/transsexual community. Do you know why these cancers are more prevalent in this population than in the heterosexual population?
There are many contributing factors that add incremental levels of health risk to this population. We found that engaging in risky lifestyle behaviors, such as smoking, consuming excessive amounts of alcohol, having unprotected sex, and being overweight or obese, tends to happen more often in the lesbian, gay, bisexual, and transgender/transsexual population. Also, on average, this population tends to have lower incomes, and as a result many do not have health insurance and are unable to see a physician for regular checkups, mental health services, hormone therapy, or gender-affirmation surgery. Not being able to find a physician who is part of this community or who is knowledgeable about this population also discourages and delays care.
Another risk factor is a lack of knowledge about cancer prevention screening strategies. For example, because a lesbian woman is not having sexual intercourse with a man, she might think she is not at risk for cervical cancer and so not have regular Pap tests. Or a gay man might not know he is at increased risk for anal warts, which increases his risk for anal cancer, and have unprotected sex.
In addition, health-care providers may not realize the increased risk for anal cancer in gay men and administer secondary prevention methods such as an anal Pap test or a digital rectal exam to detect precancerous and cancerous lesions. Also, the human papillomavirus is transmitted through gay and lesbian and heterosexual sex, so these cases are examples where sexual minorities may be at greater risk for certain cancers. It is a combination of behavior, psychosocial status, and social economic status that contributes to higher risk and higher rates of cancer in this population.
I also want to make clear that we are not saying that the elevated risk exists just in the seven cancers we mentioned in our study. These were the cancers that we could find enough data on to discuss with some certainty.
A Different Approach Needed
What can the oncology community do to improve the care of lesbian, gay, bisexual, and transgender/transsexual patients?
We have data that show oncologists believe all patients should be treated the same, regardless of their sexual status or gender identity, and we disagree because we do find differences in cancer risk and outcome in the lesbian, gay, bisexual, and transgender/transsexual population. Our study sheds light on the fact that this is a true health-disparities minority group, and oncologists need to be more aware of the uniqueness of this population.
Sexual orientation and gender identity questions should be part of health-care provider intakes, clinical trials, and academic research. As part of their care, oncologists should ask patients about their preferences, concerns, and needs regarding treatment plans and end-of-life care and acknowledge the medical rights of not just the patients, but their partners and family members as well.
This is an especially vulnerable population, and there needs to be greater awareness by the medical profession of the physical, emotional, and financial needs of the lesbian, gay, bisexual, and transgender/transsexual population.
Advocating for Change
What institutional changes would you like to see made to improve the cancer care of lesbian, gay, bisexual, and transgender/transsexual patients?
We are advocating for several changes. To begin, it would be helpful for health insurers to incorporate a link on their provider directory to the Gay and Lesbian Medical Association’s database of physicians (glma.org), which would give patients an option to seek care from a lesbian, gay, bisexual, and transgender/transsexual–friendly physician. Implementing local, state, federal, and institutional policies that reduce social disparities by being more sensitive to the needs and concerns of lesbian, gay, bisexual, and transgender/transsexual individuals would also help improve health outcomes. And including sexual orientation and gender identity information in electronic health records is essential to provide a foundation for understanding the status and needs of this population.
Finally, in addition to including sexual orientation and gender identity questions on population surveys and cancer registries such as SEER and capturing the information in electronic health records, we also need to increase lesbian, gay, bisexual, and transgender/transsexual–related research to eliminate health-care disparities and design interventions for their specific issues.
By identifying and addressing the health needs of lesbian, gay, bisexual, and transgender/transsexual patients, we can reduce health disparities and make a positive difference in their lives. ■
Disclosure: Dr. Schabath reported no potential conflicts of interest.
References
1. Quinn GP, Sanchez JA, Sutton SK, et al: Cancer and lesbian, gay, bisexual, transgender/transsexual, and queer/questioning (LGBTQ) populations. CA Cancer J Clin 65:384-400, 2015.
2. Ward BW, Dahlhamer JM, Galinsky AM, et al: Sexual orientation and health among U.S. adults: National health interview survey, 2013. Natl Health Stat Rep 77:1-10, 2014.
3. Gates GJ: How many people are lesbian, gay, bisexual and transgender? The Williams Institute, University of California, Los Angeles, School of Law; 2011. Available at http://williamsinstitute.law.ucla.edu/research/census-lgbt-demographics-studies/how-many-people-are-lesbian-gay-bisexual-and-transgender/. Accessed November 24, 2015.
