Sexual orientation and intentions to obtain breast cancer screening

"It's probably an STI because you're gay": a qualitative study of diagnostic error experiences in sexual and gender minority individuals

BACKGROUND

There is a critical need to identify specific causes of and tailored solutions to diagnostic error in sexual and gender minority (SGM) populations.

PURPOSE

To identify challenges to diagnosis in SGM adults, understand the impacts of patient-reported diagnostic errors on patients' lives and elicit solutions.

METHODS

Qualitative study using in-depth semistructured interviews. Participants were recruited using convenience and snowball sampling. Recruitment efforts targeted 22 SGM-focused organisations, academic centres and clinics across the USA. Participants were encouraged to share study details with personal contacts. Interviews were analysed using codebook thematic analysis.

RESULTS

Interviewees (n=20) ranged from 20 to 60 years of age with diverse mental and physical health symptoms. All participants identified as sexual minorities, gender minorities or both. Thematic analysis revealed challenges to diagnosis. Provider-level challenges included pathologisation of SGM identity; dismissal of symptoms due to anti-SGM bias; communication failures due to providers being distracted by SGM identity and enforcement of cis-heteronormative assumptions. Patient-level challenges included internalised shame and stigma. Intersectional challenges included biases around factors like race and age. Patient-reported diagnostic error led to worsening relationships with providers, worsened mental and physical health and increased self-advocacy and community-activism. Solutions to reduce diagnostic disparities included SGM-specific medical education and provider training, using inclusive language, asking questions, avoiding assumptions, encouraging diagnostic coproduction, upholding high care standards and ethics, involving SGM individuals in healthcare improvement and increasing research on SGM health.

CONCLUSIONS

Anti-SGM bias, queerphobia, lack of provider training and heteronormative attitudes hinder diagnostic decision-making and communication. As a result, SGM patients report significant harms. Solutions to mitigate diagnostic disparities require an intersectional approach that considers patients' gender identity, sexual orientation, race, age, economic status and system-level changes.

Disparities in cancer incidence by sexual orientation

INTRODUCTION

Cancer risk factors are more common among sexual minority populations (e.g., lesbian, bisexual) than their heterosexual peers, yet little is known about cancer incidence across sexual orientation groups.

METHODS

The 1989-2017 data from the Nurses' Health Study II, a longitudinal cohort of female nurses across the United States, were analyzed (N = 101,543). Sexual orientation-related cancer disparities were quantified by comparing any cancer incidence among four sexual minority groups based on self-disclosure-(1) heterosexual with past same-sex attractions/partners/identity; (2) mostly heterosexual; (3) bisexual; and (4) lesbian women-to completely heterosexual women using age-adjusted incidence rate ratios (aIRR) calculated by the Mantel-Haenszel method. Additionally, subanalyses at 21 cancer disease sites (e.g., breast, colon/rectum) were conducted.

RESULTS

For all-cancer analyses, there were no statistically significant differences in cancer incidence at the 5% type I error cutoff among sexual minority groups when compared to completely heterosexual women; the aIRR was 1.17 (95% CI,0.99-1.38) among lesbian women and 0.80 (0.58-1.10) among bisexual women. For the site-specific analyses, incidences at multiple sites were significantly higher among lesbian women compared to completely heterosexual women: thyroid cancer (aIRR, 1.87 [1.03-3.41]), basal cell carcinoma (aIRR, 1.85 [1.09-3.14]), and non-Hodgkin lymphoma (aIRR, 2.13 [1.10-4.12]).

CONCLUSION

Lesbian women may be disproportionately burdened by cancer relative to their heterosexual peers. Sexual minority populations must be explicitly included in cancer prevention efforts. Comprehensive and standardized sexual orientation data must be systematically collected so nuanced sexual orientation-related cancer disparities can be accurately assessed for both common and rare cancers.

Health, Economic, and Social Disparities among Lesbian, Gay, Bisexual, and Sexually Diverse Adults: Results from a Population-Based Study

We investigated health, economic, and social disparities among lesbian, gay, bisexual, and sexually diverse adults, 18 years and older. Analyzing 2011-2019 Washington State Behavioral Risk Factor Surveillance System (N = 109,527), we estimated and compared the prevalence rates of background characteristics, economic and social indicators, health outcomes, chronic conditions, health care access, health behaviors, and preventive care by gender and sexual identity. Sexual minority adults reported heightened risks of poor general health, physical and mental health, disability, subjective cognitive decline, and financial barriers to health care, compared with their straight counterparts. Economic disparities and disability were evident for lesbians and both bisexual adult women and men. We found higher rates of smoking and excessive drinking among lesbians and bisexual women, and higher rates of smoking and living alone among gay men. Sexually diverse adults experience disparities in health care access. This study is one of the first to identify disparities among sexually diverse populations, in addition to lesbian, gay, and bisexual adults. More research is required to understand the mechanisms of disparities within these groups to address their distinct intervention needs.

Scoping review of experiences of sexual minority women treated for breast cancer

PURPOSE

To summarize and critique research on the experiences and outcomes of sexual minority women (SMW) treated with surgery for breast cancer through systematic literature review.

METHODS

A comprehensive literature search identified studies from the last 20 years addressing surgical experiences and outcomes of SMW breast cancer survivors. Authors performed a quality assessment and thematic content analysis to identify emergent themes.

RESULTS

The search yielded 121 records; eight qualitative studies were included in the final critical appraisal. Quality scores for included studies ranged 6-8 out of 10. Experiences and outcomes of SMW breast cancer survivors were organized by major themes: 1) Individual, 2) Interpersonal, 3) Healthcare System, and 4) Sociocultural and Discursive.

CONCLUSIONS

SMW breast cancer survivors have unique experiences of treatment access, decision-making, and quality of life in survivorship. SMW breast cancer survivors' personal values, preferences, and support network are critical considerations for researchers and clinicians.

Sexual and Gender Minority Invisibility in Cancer Studies: A Call for Effective Recruitment Methods to Address Cancer Disparities

#LGBTQ+ people with cancer are invisibilized: A call for #intersectional cancer research (link here) #healthequity

Participation, barriers, and facilitators of cancer screening among LGBTQ+ populations: A review of the literature

The LGBTQ+ community is at higher risk of certain cancers but is less likely to participate in screening programs or engage with preventive healthcare. Despite this, the barriers and facilitators to cancer screening are not well understood in this population. We conducted a literature review of research related to LGBTQ+ participation in cancer screening, as well as barriers and facilitators to participation. Following abstract and full-text screening, 50 studies were included in the final synthesis. Compared to their heterosexual counterparts, lesbian and bisexual women were less likely to participate in cervical cancer screening and mammography, but gay and bisexual men were more likely to participate in anal and colorectal cancer screening. Transgender individuals had lower rates of screening than cisgender individuals for all cancer types. Barriers to participation were found at the individual-, provider-, and administrator-level, and good communication with a healthcare provider was the strongest facilitator. These results provide reasonable first steps toward improving participation rates for LGBTQ+ populations in cancer screening. Patient-centered approaches should draw on core guiding principles to inform the provision of care, including anticipating LGBTQ+ patients, improving knowledge about care for these patients, and confronting individually-held biases that may affect care, in order to improve care experiences and participation rates in preventive services.

Recruiting an underserved, difficult to reach population into a cancer trial: Strategies from the Restore-2 Rehabilitation Trial for gay and bisexual prostate cancer patients

BACKGROUND/AIMS

Sexual minorities are small and under-researched populations that are at disproportionate risk for cancer and poor cancer outcomes. Described as a "hidden population," the principal research challenge has been to develop effective methods to identify and recruit such cancer patients into cancer studies. Online recruitment strategies, as well as targeted clinic recruitment using patient-entered sexual orientation and gender identity data from electronic medical records have potential to transform recruitment, but studies testing the effects of how to recruit using these have not been published.

METHODS

In 2019, we conducted a naturalistic, three-arm, stratified prospective study to compare three recruitment strategies: (a) clinic based recruitment of prostate cancer patients from gay health and urology clinics; (b) directly from the gay community; and (c) online recruitment (through cancer support, sex/dating, and social sites). For each strategy, we estimated time, workload, and direct costs involved. To study how recruitment strategy may affect sampling, we tested for retention rates, demographic and outcome differences across sites. Using these methods, we successfully recruited 401 gay and bisexual prostate cancer patients into a randomized, controlled, 24-month trial testing an online sexual and urinary rehabilitation curriculum tailored for this population.

RESULTS

There were seven key results. First, it is possible to recruit substantial numbers of sexual minority men into prostate cancer studies provided online recruitment methods are used. Second, we observed big differences in dropout during study onboarding by recruitment source. Third, within online recruitment, the online sex/dating application (app) was the most successful and efficient, followed by the cancer support site, and then the social networking site. Fourth, while clinics were the cheapest source of recruitment, they were time intensive and low in yield. Fifth, the cancer support site and sex/dating app recruits differed by several characteristics, with the former being more rehabilitation-focused while the latter were younger and more sexually active. Sixth, we found almost no differences in outcomes across the three online recruitment sites. Seventh, because retention in online studies has been a concern, we confirm very low attrition at 3- and 6 months into the trial.

CONCLUSION

For sexual minority cancer research, more research on how to use sexual orientation and gender identity electronic medical record data for clinic-based recruitment is needed. For other small or hard-to-reach populations, researchers should compare and publish online versus offline recruitment strategies.

Beyond Black and White: race and sexual identity as contributors to healthcare system distrust after breast cancer screening among US women

OBJECTIVE

Healthcare system distrust (HCSD) has been linked to poor breast cancer outcomes. Previous HSCD analyses have focused on Black-White disparities; however, focusing only on race ignores the complex set of factors that form identity. We quantified the contributions of race and sexual minority (SM) identity to HCSD among US women who had received breast cancer screening.

METHODS

This cross-sectional study used intersectionality decomposition methods to assess the degree to which racial and SM identity contributed to disparate responses to the validated 9-item HCSD Scale. The sample included online survey participants identifying as a Black or White woman living in the US, with a self-reported abnormal breast cancer screening result in the past 24 months and/or breast cancer diagnosis since 2011.

RESULTS

Of 649 participants, 49.4% of Black SM women (n = 85) were in the highest HCSD tertile, followed by 37.4% of White SM women (n = 123), 24.4% of Black heterosexual women (n = 156), and 19% of White heterosexual women. Controlling for age, 72% of the disparity in HCSD between Black SM women and White heterosexual women was due to SM status, 23% was due to racial identity, and 3% was due to both racial and SM identity.

CONCLUSIONS

SM identity emerged as the largest driver of HCSD disparities; however, the combined racial and SM disparity persisted. Excluding sexual identity in HCSD studies may miss an important contributor. Interventions designed to increase the HCS's trustworthiness at the provider and system levels should address both racism and homophobia.

The Annual Examination for Lesbian, Gay, and Bisexual Patients

The annual examination is a comprehensive evaluation of patients in which all aspects of health and well-being are considered, including proper screening, appropriate preventive care, and recommendations and resources for healthy living. Clinicians commonly avoid certain topics with lesbian, gay, bisexual, transgender, and queer (LGBTQ) patients because they may be unprepared to address their health needs. Therefore, clinicians should learn how to conduct an LGBTQ-friendly annual examination in order to provide high-quality care. This article focuses on both the general and unique health needs of lesbian, gay, bisexual, and queer patients; care for transgender and gender-diverse patients is considered elsewhere.

A Model-Based Meta-Analysis of Willingness to Participate in Cancer Screening

Although early screening tests are beneficial for the detection and treatment of cancers, many people have failed to participate in screening tests. The present study aims to explore the theoretical underpinning of low participation in screening programs using the method of meta-analytic structural equation modeling. It was found that the health belief model is the most adopted theoretical framework. Moreover, the intended uptake of screening was positively predicted only by cues to action, health literacy, and perceived susceptibility. As a result, a health intention model, including the three significant variables, is proposed. The practical implications of the findings are that health communication campaigns should focus on enlightening and engaging the public through all necessary means to raise awareness and transfer knowledge in relation to screening procedures as well as cancers per se.

"This is some mess right here": Exploring interactions between Black sexual minority women and health care providers for breast cancer screening and care

BACKGROUND

Few studies have explored how the intersection of race and sexual identity contribute to breast cancer disparities for Black sexual minority women (SMW). Issues within patient-provider relationships, including bias, contribute to health disparities for minority groups. The authors used constructs from self-determination theory (SDT) to explore the nature of health care provider interactions in breast cancer screening and care among Black SMW.

METHODS

Participants were sampled nationally through social media, targeted emails, and referrals. Qualitative, in-depth interviews were conducted with 15 Black cisgender SMW, ages 38 to 64 years, who had a breast cancer diagnosis or recent abnormal mammogram. Interviews were conducted face-to-face or online, audio-recorded, and transcribed verbatim. Two analysts coded the interviews. Codes were analyzed across interviews to identify themes salient to SDT.

RESULTS

Themes aligned with the SDT constructs of relatedness and autonomy. Some participants discussed feeling most understood by Black and/or female providers who shared at least 1 of their identities. Feeling understood through shared identity contributed to participants feeling seen and heard by their providers. Participants who discussed negative experiences with providers believed that the provider made negative assumptions about them based on their race and/or sexual orientation.

CONCLUSIONS

When interacting with health care providers for breast cancer screening and care, Black SMW face specific challenges related to their multiply marginalized social position. Reducing health care provider bias toward Black SMW may improve patients' desires to continue in care. Providing equitable care while acknowledging and respecting women with multiply marginalized identities may improve the nature of these interactions.

The Role of Butch versus Femme Identity in Body Image and Breast Health Among Lesbians in Taiwan: Results of an Online Survey

PURPOSE

The views of butch- and femme-identified lesbians toward their own breasts, breast cancer, breast cancer screenings, and their behavior and intentions toward breast health care were examined and compared in this study.

METHODS

A total of 208 Taiwanese lesbians (134 butch-identified lesbians and 78 femme-identified lesbians) completed an online survey.

RESULTS

Butch-identified lesbians were more likely to hold negative views regarding their own breasts, which were found to be significantly and negatively associated with their actions in performing breast self-examinations when compared with femme-identified lesbians.

CONCLUSIONS

Healthcare providers should be aware of and provide culturally competent care to lesbians with different identities.

CLINICAL RELEVANCE

The results can be employed as evidence for promoting lesbians' breast health, particularly butch-identified lesbians. Healthcare providers should provide a supportive environment in order to promote a positive body image and improve breast health among lesbians.

Modifiers of Cancer Screening Prevention Among Sexual and Gender Minorities in the Behavioral Risk Factor Surveillance System

PURPOSE

Increasing social acceptance of sexual and gender minorities may not translate to parity in health care access and health outcomes. Sexual orientation and gender identity (SOGI) may continue to contribute to differences in preventive health behavior including cancer screening. Our purpose was to estimate the independent effect of SOGI on breast, cervical, and colorectal cancer screening adherence.

METHODS

We used sampling weighted data from 2016 Behavioral Risk Factor Surveillance System. We defined breast, cervical, and colorectal cancer screening using the US Preventive Services Task Force guidelines. All survey data were self-reported including demographic and medical information. We calculated the prevalence of screening by sexual orientation (straight, lesbian or gay, bisexual) and gender identity (cisgender, transgender). The term "sexual and gender minorities" in our study refers to lesbian or gay, bisexual, and transgender individuals. Logistic regression models assessed independent effect of SOGI on screening adherence.

RESULTS

Prevalence of breast, cervical, and colorectal cancer screening varied significantly by SOGI. After adjusting for other variables, bisexual persons had significantly lower odds (odds ratio [OR] = 0.60, 95% confidence interval [CI] = 0.38-0.93) of breast cancer screening adherence. Lesbian or gay persons had significantly decreased likelihood (OR = 0.53, 95% CI = 0.29-0.95) of cervical cancer screening adherence. Although rate of colorectal cancer screening adherence varied significantly by SOGI, we did not find an independent effect of SOGI and colorectal cancer screening adherence after adjusting for other variables. No independent effect of gender identity categories on breast, cervical, and colorectal cancer screening adherence was detected. Social determinants of health, such as health care access and insurance, that disproportionately disadvantaged bisexual individuals independently influenced screening adherence.

CONCLUSIONS

SOGI can affect cancer screening adherence. Bisexual individuals had worse health care access and socioeconomic hardships among sexual and gender minorities. Given the independent effects of social determinants of health on cancer screening adherence, more attention needs to be paid to sexual and gender minorities, especially bisexual population.

Patient-physician relationships, health self-efficacy, and gynecologic cancer screening among women with Lynch syndrome

Background

Lynch syndrome, a hereditary cancer syndrome, predisposes women to colorectal, endometrial, and ovarian cancer. Current guidelines recommend that women with Lynch syndrome undergo risk-reducing gynecological surgery to reduce their chances of developing endometrial or ovarian cancer. Little is known about how women with Lynch syndrome perceive gynecological cancer screening, or the psychosocial factors associated with screening attitudes and behaviour.

Methods

This study used a cross-sectional, quantitative design. Using self-report questionnaire data from a sample of women with Lynch syndrome (N = 50) who had not undergone risk-reducing surgery, the current study sought to: 1) describe the gynecological cancer screening behaviours of women with Lynch syndrome, as well participant-reported sources of information about Lynch syndrome; 2) examine the extent to which women believe gynecological cancer screening is effective and provides them with reassurance and; 3) assess to what extent relationships with one’s family physician were associated with gynecological cancer screening, perceptions about screening, and health self-efficacy. Data were analyzed using descriptive statistics and Spearman rank-ordered correlations.

Results

Data analyses showed that transvaginal ultrasound was the most common screening behaviour (57%) followed by pelvic ultrasound (47%). Only 22% of participants underwent endometrial biopsy. Patient-physician relationships were related to greater health self-efficacy to manage Lynch syndrome and greater perceived effectiveness of gynecological screening. However, health self-efficacy and better patient-physician relationships were not associated with increased engagement in gynecological cancer screening.

Conclusions

The data suggest that feeling efficacious about managing one’s Lynch syndrome and screening is related to positive interactions and communication with one’s family physician. While this is encouraging, future research should examine educating both family physicians and patients about current guidelines for Lynch syndrome gynecological screening recommendations.

A scoping review of sexual minority women's health in Latin America and the Caribbean

OBJECTIVES

Despite research documenting significant health disparities among sexual minority women (lesbian, bisexual, and other non-heterosexual women) in high-income countries, few studies of sexual minority women's health have been conducted in low- and middle-income countries. The purpose of this scoping review was to examine the empirical literature related to the health disparities and health needs of sexual minority women in Latin America and the Caribbean (LAC), and to identify research gaps and priorities.

DESIGN

A scoping review methodology was used.

DATA SOURCES

We conducted a comprehensive search of seven electronic databases. The search strategy combined keywords in three areas: sexual minority women, health, and LAC. English, Spanish, and Portuguese language studies published through 2017 in peer-reviewed journals were included.

REVIEW METHODS

A total 1471 articles were retrieved. An additional 5 articles were identified following descendancy search; 3 of these met inclusion criteria. After removal of duplicates and title and abstract screening, we screened the full text of 37 articles, of which 22 (representing 18 distinct studies) met inclusion criteria. At least two authors independently reviewed and abstracted data from all articles.

RESULTS

More than half of the studies were conducted in Brazil (n = 9) and Mexico (n = 5). Sexual health was the most studied health issue (n = 11). Sexual minority women were at elevated risk for sexually transmitted infections related to low use of barrier contraceptive methods during sexual encounters with men. Findings suggest that sexual minority women are generally distrustful of healthcare providers and view the healthcare system as heteronormative. Providers are believed to lack the knowledge and skills to provide culturally competent care to sexual minority women. Sexual minority women generally reported low levels of sexual health education and reluctance in seeking preventive screenings due to fear of mistreatment from healthcare providers. Sexual minority women also reported higher rates of poor mental health, disordered eating, and substance use (current tobacco and alcohol use) than heterosexual women. Gender-based violence was identified as a significant concern for sexual minority women in LAC.

CONCLUSIONS

Significant knowledge gaps regarding sexual minority women's health in LAC were identified. Additional investigation of understudied areas where health disparities have been observed in other global regions is needed. Future research should explore how the unique social stressors sexual minority women experience impact their health. Nurses and other healthcare providers in the region need training in providing culturally appropriate care for this population.

Breast Cancer Screening and Care Among Black Sexual Minority Women: A Scoping Review of the Literature from 1990 to 2017

Introduction: Black women are more likely to be diagnosed at later stages of breast cancer compared with White women due to lower frequency of screening and lack of timely follow-up after abnormal screening results. Disparities in breast cancer screening, risk, and mortality are present within both Black women and sexual minority communities; however, there exists limited research concerning breast cancer care among Black sexual minority women. Materials and Methods: This scoping review examines the literature from 1990 to 2017 of the breast cancer care continuum among Black sexual minority women, including behavioral risk factors, screening, treatment, and survivorship. A total of 91 articles were identified through PubMed, PsycINFO, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases. Fifteen articles were selected for data extraction, which met the criteria for including Black/African American women, discussing breast cancer care among both racial and sexual minorities, and being a peer-reviewed article. Results: The 15 articles were primarily within urban contexts, and defined sexual minorities as lesbian or bisexual women. Across all the studies, Black sexual minority women were highly under-represented, and key conclusions are not fully applicable to Black sexual minority women. Sexual minority women had a higher prevalence of breast cancer risk factors (i.e., nulliparity, fewer mammograms, higher alcohol intake, and lower oral contraceptive use). Furthermore, some studies noted homophobia from health providers as potential barriers to engagement in care for sexual minority women. Conclusions: The lack of studies concerning Black sexual minority women in breast cancer care indicates the invisibility of a group that experiences multiple marginalized identities. More research is needed to capture the dynamics of the breast cancer care continuum for Black sexual minority women.

Teaching Health-Care Providers to Query Patients With Cancer About Sexual and Gender Minority (SGM) Status and Sexual Health

End of life is difficult for all patients but sexual and gender minorities (SGM) are prone to isolation and loneliness, especially if their SGM status is unknown or unaccepted. In oncology clinics, where goals of care discussions about end of life are integral and frequent, querying patients about their SGM status and sexual health is of particular importance. The American Society of Clinical Oncology recently released a position statement that called for greater focus on SGM populations with the goal of reducing and eventually eliminating disparities in cancer care within this group. An important first step in addressing such disparities is learning how best to train cancer health-care providers to ask patients about their SGM status and about sexual health in general. This article summarizes the mandate for understanding cancer issues in SGM populations and the dearth of cancer-related data within this group. This article also describes an ongoing 3-part study intended to build a mini curriculum with the goal of helping cancer health-care providers to ask patients with cancer about SGM status and to ask all patients with cancer about sexual health issues. The results of this ongoing study could potentially improve end-of-life care for subgroups of patients.

Acquisition of sexual orientation and gender identity data among NCI Community Oncology Research Program practice groups

BACKGROUND

Sexual and gender minority individuals face numerous cancer-related inequities, many of which appear to be underreported. However, to the best of the authors' knowledge, no one has assessed rates of acquisition of sexual orientation and gender identity (SOGI) data within community oncology settings.

METHODS

Community oncology practices that were part of the NCI Community Oncology Research Program (NCORP) network were asked whether they routinely collected SOGI information and coded this information in their electronic medical records. The proportion of practice groups reporting routine collection of sexual and/or gender minority information was calculated. Potential associations between the collection of SOGI information and practice group-level and state-level characteristics (from Gallup poll data) were also provided.

RESULTS

Twenty-four percent of the responding NCORP practice groups reported routine collection of sexual orientation information, and 10% reported collection of gender identity information. Practices located in western regions of the United States, practices in states with higher proportions of sexual and gender minority-identifying individuals, and practices with lower proportions of non-Hispanic patients were more likely to ask patients about sexual orientation and/or gender identity.

CONCLUSIONS

US oncology practices that participate in research do not frequently collect SOGI information from patients with cancer. Educational initiatives should inform oncology staff and providers about the importance of collecting gender identity and sexual orientation information to improve existent disparities faced by sexual and gender minority patients.

Intersectionality and the LGBT Cancer Patient

OBJECTIVES

To present the ways in which race, ethnicity, class, gender, and sexual orientation interact in the context of cancer risk, access to care, and treatment by health care providers. Cancer risk factors, access to care, and treatment for lesbian, gay, bisexual, and transgender (LGBT) patients are discussed within the context of intersectionality and cultural humility.

DATA SOURCES

Peer reviewed articles, cancer organizations, and clinical practice.

CONCLUSION

LGBT patients have multiple identities that intersect to create unique experiences. These experiences shape their interactions with the health care system with the potential for positive or negative consequences. More data is needed to describe the outcomes of those experiences and inform clinical practice.

IMPLICATIONS FOR NURSING PRACTICE

Oncology nurses have an obligation to acknowledge patients' multiple identities and use the practice of cultural humility to provide individualized, patient-centered care.

Social Determinants of LGBT Cancer Health Inequities

OBJECTIVES

To describe the extant literature on social determinants of health as they relate to the cancer disparities and to highlight the research findings relating to lesbian, gay, bisexual, and transgender (LGBT) populations.

DATA SOURCES

Published scientific literature and clinical literature, and published reports from the World Health Organization and US Department of Health and Human Services.

CONCLUSION

The larger literature on health inequities is moving beyond individual-level predictors of risk to evaluate the influence of social determinants of health on the persistent health inequalities in a population. As it has for other groups, additional research into social determinants of health for LGBT persons of color may play an important role in identifying and reducing cancer inequities for this group.

IMPLICATIONS FOR NURSING PRACTICE

Increased awareness of the factors that contribute to health inequities for the LGBT population may provide insight into improving patient-provider relationships with LGBT patients. A large body of experiential and clinical knowledge positions nurses to conduct meaningful research to expand the current understanding of the social determinants of LGBT cancer health inequities.

Cancer and the LGBTQ Population: Quantitative and Qualitative Results from an Oncology Providers' Survey on Knowledge, Attitudes, and Practice Behaviors

Background: Despite growing social acceptance, the LGBTQ population continues to face barriers to healthcare including fear of stigmatization by healthcare providers, and providers’ lack of knowledge about LGBTQ-specific health issues. This analysis focuses on the assessment of quantitative and qualitative responses from a subset of providers who identified as specialists that treat one or more of the seven cancers that may be disproportionate in LGBTQ patients. Methods: A 32-item web-based survey was emailed to 388 oncology providers at a single institution. The survey assessed: demographics, knowledge, attitudes, and practice behaviors. Results: Oncology providers specializing in seven cancer types had poor knowledge of LGBTQ-specific health needs, with fewer than half of the surveyed providers (49.5%) correctly answering knowledge questions. Most providers had overall positive attitudes toward LGBTQ patients, with 91.7% agreeing they would be comfortable treating this population, and would support education and/or training on LGBTQ-related cancer health issues. Conclusion: Results suggest that despite generally positive attitudes toward the LGBTQ population, oncology providers who treat cancer types most prevalent among the population, lack knowledge of their unique health issues. Knowledge and practice behaviors may improve with enhanced education and training on this population’s specific needs.

Disparities in Cancer Screening Practices among Minority and Underrepresented Populations

OBJECTIVES

To review current evidence about cancer screening challenges that lead to cancer health disparities in minority populations.

DATA SOURCES

Research reports, published journal articles, web sites, and clinical practice observations.

CONCLUSION

There are significant disparities that exist in cancer screening practices among racial and ethnic minority and underrepresented populations, resulting in disproportionately higher cancer mortality rates in these populations.

IMPLICATIONS FOR NURSING PRACTICE

Nurses are positioned to lead in educating, promoting, and bringing awareness to cancer screening recommendationsand current cancer prevention guidelines for at-risk individuals, and help them to implement these guidelines to reduce incidence and mortality.

Clinical Considerations of Risk, Incidence, and Outcomes of Breast Cancer in Sexual Minorities

BACKGROUND

Breast cancer is a leading cause of cancer-related mortality in women. Limited research exists on the impact of sexual orientation on overall risk of and mortality from breast cancer. We sought to summarize the medical literature on breast cancer in sexual minority women and identify possible disparities in this population.

METHODS

A comprehensive literature search was conducted for English-language studies in peer-reviewed medical journals that referenced breast cancer and sexual minority, lesbian, bisexual, or transgender individuals. Articles published between January 2000 and November 2015 were included. They were reviewed for relevance to breast cancer risk stratification, breast cancer mortality, breast reconstruction, and transgender issues.

RESULTS

Behavioral risks, reproductive risks, and risks associated with decreased access to health care may all affect outcomes for sexual minorities with breast cancer. Limited studies have mixed results regarding mortality associated with breast cancer in sexual minorities due to an inconsistent reporting of sexual orientation.

CONCLUSIONS

Overall, the research examining breast cancer in sexual minority women remains limited. This finding is likely due to limitations in the reporting of sexual orientation within large databases, thus making broader-scale research difficult.

A systematic review of the literature on weight in sexual minority women

BACKGROUND

Over the past 20 years, a growing literature has demonstrated that sexual minority women have greater weight than heterosexual women, prompting concern that they may be at high risk for disparities in physical disorders. In 2008, Bowen et al. published a review of the existing research on sexual minority women and obesity, finding no methodologically strong studies with representative sampling procedures.

METHOD

We conducted a systematic review of the literature covering the period of July 2006 to February 2014 on the relationship between sexual orientation and weight. The review includes 20 population-based and 17 nonprobability sample studies.

CONCLUSIONS

The majority of these studies found that lesbian and bisexual women had significantly greater body mass index (BMI) or a higher percentage with a BMI over 30 than heterosexual women. The difference in BMI was fairly consistent across the lifespan, with the weight differences beginning in adolescence. The studies, however, did not show a higher prevalence of physical disorders thought to be associated with weight. This potentially paradoxical finding warrants further research to compare prevalence of chronic disease by BMI category and sexual orientation.

Cancer and lesbian, gay, bisexual, transgender/transsexual, and queer/questioning (LGBTQ) populations

This article provides an overview of the current literature on seven cancer sites that may disproportionately affect lesbian, gay, bisexual, transgender/transsexual, and queer/questioning (LGBTQ) populations. For each cancer site, the authors present and discuss the descriptive statistics, primary prevention, secondary prevention and preclinical disease, tertiary prevention and late-stage disease, and clinical implications. Finally, an overview of psychosocial factors related to cancer survivorship is offered as well as strategies for improving access to care.

Chronic Physical Health Problems in Sexual Minority Women: Review of the Literature

Although there is substantial literature about sexual minority women's mental health and use of alcohol, tobacco, and other drugs (ATOD), only recently has attention been focused on chronic physical health disorders thought to stem from stress and exposure to ATOD use. The most extensively studied aspect of physical health has been weight, with the majority of studies reporting higher prevalence of overweight and obesity. In addition, many studies report higher levels of stressful experiences in both childhood and adulthood for sexual minority women. In this paper, the hypothesized relationship between stress, unhealthy behaviors, and five common chronic physical health disorders is explored via review of the literature. Only asthma appeared to be consistently more common in sexual minority women, and few or no differences in diabetes, hypertension, cardiovascular disease, and most cancers were found. The limitations of these studies are reviewed, and the need for studies that directly address the relationships among stress, health-damaging practices, and chronic disorder is emphasized. However, if these findings hold up, and sexual minority women are not more prone to these disorders, the field may need better theoretical frameworks from which to explore potential differences in the manifestation of mental versus chronic physical health disparities.

Mediation by peer violence victimization of sexual orientation disparities in cancer-related tobacco, alcohol, and sexual risk behaviors: pooled youth risk behavior surveys

OBJECTIVES

We examined the role of adolescent peer violence victimization (PVV) in sexual orientation disparities in cancer-related tobacco, alcohol, and sexual risk behaviors.

METHODS

We pooled data from the 2005 and 2007 Youth Risk Behavior Surveys. We classified youths with any same-sex sexual attraction, partners, or identity as sexual minority and the remainder as heterosexual. We had 4 indicators of tobacco and alcohol use and 4 of sexual risk and 2 PVV factors: victimization at school and carrying weapons. We stratified associations by gender and race/ethnicity.

RESULTS

PVV was related to disparities in cancer-related risk behaviors of substance use and sexual risk, with odds ratios (ORs) of 1.3 (95% confidence interval [CI] = 1.03, 1.6) to 11.3 (95% CI = 6.2, 20.8), and to being a sexual minority, with ORs of 1.4 (95% CI = 1.1, 1.9) to 5.6 (95% CI = 3.5, 8.9). PVV mediated sexual orientation disparities in substance use and sexual risk behaviors. Findings were pronounced for adolescent girls and Asian/Pacific Islanders.

CONCLUSIONS

Interventions are needed to reduce PVV in schools as a way to reduce sexual orientation disparities in cancer risk across the life span.

Health disparities among lesbian, gay, and bisexual older adults: results from a population-based study

OBJECTIVES

We investigated health disparities among lesbian, gay, and bisexual (LGB) adults aged 50 years and older.

METHODS

We analyzed data from the 2003-2010 Washington State Behavioral Risk Factor Surveillance System (n = 96 992) on health outcomes, chronic conditions, access to care, behaviors, and screening by gender and sexual orientation with adjusted logistic regressions.

RESULTS

LGB older adults had higher risk of disability, poor mental health, smoking, and excessive drinking than did heterosexuals. Lesbians and bisexual women had higher risk of cardiovascular disease and obesity, and gay and bisexual men had higher risk of poor physical health and living alone than did heterosexuals. Lesbians reported a higher rate of excessive drinking than did bisexual women; bisexual men reported a higher rate of diabetes and a lower rate of being tested for HIV than did gay men. Conclusions. Tailored interventions are needed to address the health disparities and unique health needs of LGB older adults. Research across the life course is needed to better understand health disparities by sexual orientation and age, and to assess subgroup differences within these communities.

Invisible and at risk: STDs among young adult sexual minority women in the United States

CONTEXT

Sexual minority women are not adequately assessed by national STD surveillance systems, and research regarding STD burden in nationally representative samples of such women is rare. Moreover, few studies have assessed STD risk exclusively among young adult women.

METHODS

Wave 4 (2007-2008) data from the National Longitudinal Study of Adolescent Health on 7,296 females aged 24-32 were used to examine the relationship between sexual orientation and receipt of an STD diagnosis in the past year. Multivariate logistic regression analyses used two measures of sexual orientation: sexual identity and gender of sex partners.

RESULTS

Eighty percent of women considered themselves straight; 16% mostly straight; and 4% bisexual, mostly gay or gay. Eighty-five percent had had only male partners, while 7% had had one female partner, and 8% two or more female partners. In unadjusted models, women who identified themselves as mostly straight were more likely than straight women to have had an STD (odds ratio, 1.4); mostly gay or gay women were at lower risk (0.4). Women who had had two or more female partners had a higher STD risk than did women who had had only male partners (1.7). Adjusting for social and demographic characteristics did not substantially alter these results; however, the associations between sexual identity, gender of sex partners and STD diagnosis were eliminated after adjustment for sexual behaviors (e.g., having had anal sex).

CONCLUSIONS

Sexual identity, gender of sex partners and sexual behaviors should be taken into account in assessments of women's STD risk.

Cancer knowledge in the plural: queering the biopolitics of narrative and affective mobilities

In this age of DIY Health-a present that has been described as a time of "ludic capitalism"-one is constantly confronted with the injunction to manage risk by means of making healthy choices and of informed participation in various self-surveillant technologies of bioinformatics. Neoliberal governmentality has been redacted by poststructuralist scholars of bioethics as defined by the two-fold emergence of, on the one hand, populations and on the other, the self-determining individual-as biopolitical entities. In this article, we provide a genealogical-phenomenological schematization (GPS analysis) of the narration of cancer in relation to "sexual minority populations." Canonical discourses concerning minority sexualities are articulated by means of a logic of "inclusion and reification" that organizes the interiorization of norms of embodied relationality, and a positive liaison with biomedical technologies and techniques in the taking up of a rhetorical style of biographical compliance. Neoliberal DIY Health logics conflate participation with agency, and institute norms of recognition that constrain visibility to: citizens who make healthy choices and manage risk, heroic cancer stories, stories of the reconstruction of states of normalcy, or of survival against all odds. Alternatively, we trace the performative articulations of queer narrative practices that constitute an ephemeral, nomadic praxiology-a doing of knowledge in cancer's queer narration. Queer cancer narrative practices represent a relationship to health and embodiment that is predicated, not on normalcy, but predicated on troubling norms, on artful failure, and on engaging in a kind of affective mapping that might be thought constitutive of a speculative bioethical relation to the self as other.

Modern Advances in Genetic Testing: Ethical Challenges and Training Implications for Current and Future Psychologists

The ethical implications for psychological practice of genetic testing are largely unexplored. Predictive testing can have a significant impact on health and well-being, and increasing numbers of individuals with knowledge of their risk for various disorders are likely to present for psychotherapy. In addition, more people will struggle with the decision of whether to obtain information regarding their genetic material. Psychologists will need to have the appropriate knowledge and clinical skills to effectively counsel this population. This article highlights the relevant ethical issues surrounding psychological treatment of individuals pursuing or considering undergoing genetic testing. These issues are extended to psychologists working in research, education, and policy domains. Recommendations for graduate training programs to facilitate current and future practitioner competence are also discussed.