Two-part questions can improve cancer care in LGBTQ patients


Evidence suggests that lesbian, gay, bisexual, transgender and queer (LGBTQ) people have faced delays and disparities in cancer care for years. When Kelly S. Haviland, PhD, FNP-BC, heard about a transgender man whose breast cancer diagnosis was delayed, her passion was sparked and she changed her doctoral thesis to focus on this population.

“Although I don’t have the experience of being a trans person, I have the experience of being a lesbian woman, also presenting myself to health care with some disparities”, Haviland, nurse researcher and nurse family practitioner at Memorial Sloan Kettering Cancer Center, said.

This was in the early 2000s, and while LGBTQ issues are more recognized than ever, there is still a long way to go. Haviland discussed ways that LGBTQ cancer care can be improved in a recent interview with Oncology Nursing News.

Oncology Nursing News: Has care for LGBTQ people improved over the past 2 decades? And what more needs to be done?

Haviland: I think it’s complicated. On the one hand, the recognition of the existence of disparities and marginalizations within these populations is becoming more and more frank. And at the same time, there are, I think, over 400 different legislative policies that have been proposed this year against transgender people. So I think that while we see that the issues are being discussed more and more, we also see a lot of laws and legislative policies that come into play that are prohibitive. I think this is a difficult answer.

I think we have a long way to go in implementing and integrating education for sexual and gender minorities into all the training of our nurses, doctors, assistant doctors, associates and fellow doctors. And I know that while we need to have specific courses that outline the disparities in LGBTQ populations, we also need to integrate LGBTQ patients in our language. For example, when we do case reviews, or case studies, part of the demographics should naturally be non-heterosexual and non-cisgender people. This is part of where we need to go.

In addition to providing a safe environment [we need] research. We do not collect federal research on demographic data on sexual orientation and gender identification. So we don’t know the numbers; we have data with some of these national registers, but the SEER [Surveillance, Epidemiology, and End Results Program] does not collect research on sexual and gender minorities. So we don’t know what numbers we have in our general population for risk factors for cancer surveillance, for cancer prevalence. We have smaller studies and some state-based studies and… CDC data. So we can make inferences based on this data. But we don’t have numbers like we do for heterosexual and cisgender populations. So I think that’s another area that we really need to be able to look at and open up so that we can assess and really see what’s going on (to create) safe and welcoming environments in our facilities and clinical arenas.

What does a safe and welcoming environment look like?

Having a welcoming environment means having a physical representation of different types of people. And we’re not just talking about same-sex couples or transgender people, but all the different people. It is also very important to examine the intersectionality not only of gender, sexual orientation, but also of race, ethnicity and cultural diversity. And with these ideas in mind, we make sure we create individualized, personalized cancer care for everyone. This involves asking questions about sexual orientation and gender identification, ensuring that our electronic medical records have sex assigned at birth and gender identity.

How can nurses and other clinicians feel more comfortable with these conversations with patients?

An organ inventory is a great way to be able to really assess the tests that a person may need. For example, do you have a uterus? And it can be for someone who has had a hysterectomy for a multitude of reasons, not just a transgender person. So do you have ovaries? Do you have a uterus? Do you have a prostate? What organs do you want to assess for cancer risk? Looking at it like an organ inventory, and saying, “These are some questions I’m going to ask you, and they might sound a little funny at first. It may sound obvious, but we really try to make sure that we give each individual individual care.

When we ask questions about sex and gender, they should be two-part questions. The first may be “what is your sex at birth?” “And the second can be” what is your sex? And this is how it is recommended to collect data and track this data in electronic medical records. So when a person may have been assigned to a female at birth their gender is male, then we might be more inclined to ask these questions about having a uterus, ovaries, and breast tissue. There are many things that lead to the next question. [Clinicians should also ask] about sexual orientation, and if that person says, “Well, what do you mean? You can say, “Well, some people are straight, some people identify as lesbians, some people identify as bisexual,” and we can explain these things in a comfortable way and say that any of these things is for me to be able to provide you with the best information to screen for cancer. Or in any area where we work.

There are a lot of things we need to keep in mind when talking about cancer risks and screening.

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