Oncology healthcare providers’ knowledge, attitudes, and practice behaviors regarding LGBT health
Introduction
The lesbian, gay, bisexual, transgender (LGBT) population is known by a variety of acronyms and nomenclature. Recently, the National Institutes of Health suggested use of the term sexual and gender minority (SGM) [1] as a way to be inclusive of all populations and individuals “whose sexual orientation…is not exclusively heterosexual, [or] whose gender identity differs from the sex assigned to them at birth; [or] who vary from or reject traditional cultural conceptualizations of gender in terms of male-female dichotomy.” [1] SGMs are an understudied and underserved population often disproportionately affected by mental health issues such as depression and social isolation [2]. As such, these mental health issues are correlated with behavioral risk factors such as smoking and obesity, as well as drug and alcohol use that are directly related to increased cancer risk [2], [3], [4]. As a whole, the SGM population may face worse health outcomes due to barriers to care, lack of comfort in disclosing sexual orientation and gender identity which precludes providers from offering appropriate education and counseling for reduction of risk behaviors [5], and prior negative healthcare experiences which may prevent this population from seeking future healthcare [6]. Moreover, SGMs have potentially greater risks for several types of cancer due to their increased prevalence of risk factors and aforementioned behavior [7]. High rates of tobacco use are associated with increased risk of several types of cancer [8]. Multiple studies show higher rates of tobacco use among SGM populations compared to the general population [8], [9], [10]. Increased risk of breast cancer is linked to high rates of smoking, nulliparity, obesity, and alcohol use, all of which are more prevalent in the female SGM populations than the general population [11], [12]. Because of sexual practices such as receptive anal intercourse, men who have sex with men (MSM) are at greater risk of anal cancer as a consequence of oncogenic human papillomavirus (HPV) infection than heterosexual men [13].
Previous research has demonstrated there is limited SGM education in medical schools. For example, a study of 132 medical schools in the US and Canada found the median reported combined hours dedicated to LGBT content was 5 h and 33.3% of these schools reported no required clinical hours for LGBT content [14]. Medical students with increased clinical exposure to LGBT patients had more positive attitudes towards this population and better knowledge of their healthcare concerns compared to students who had no formal training [15].
The 2014 Association of American Medical Colleges (AAMC) report aimed to improve the LGBT healthcare [16] and suggested providers should be attentive and sensitive to patients’ needs and for physicians to understand “the whole” of a person, including sexual orientation and gender history. Furthermore, the AAMC emphasized the need for cultural competency in the care of LGBT patients with integration of this concept into the medical school curriculum [16]. Additionally, the 2011 Institute of Medicine (IOM) report identified that current research on the LGBT population was sparse [2]. Due to limited research on the education and counseling needs of the community, clinicians may lack resources and information on how best to provide this care to SGM patients [2]. Lack of cultural competency also provides a barrier to addressing the major health concerns of SGM patients. SGM patients who receive care from a provider who is uncomfortable or lacks cultural competency may experience reduced quality of care. Key areas in need of reform, identified by the IOM, are provider attitudes and education [2]. Another limitation of studying LGBT populations is that the majority of cancer registries and medical records have not collected sexual orientation and gender identity (SOGI) demographic information in the past [17]. However, a decision made by the Department of Health and Human Services in October, 2015, will require those Electronic Health Record (EHR) systems with CEHRT certification to create a platform to begin collecting SOGI in 2016 [18].
A study among elder LGBT patients receiving non-cancer related care suggested difficulty in disclosing SOGI to their providers [19] and poorer health outcomes for patients of all ages who do not disclose sexual orientation [20]. This led us to initiate a study to inquire about the knowledge, attitudes and practice behaviors of providers at a single, National Cancer Institute-designated comprehensive cancer center regarding LGBTQI patient care. At the time of the survey we used the term LGBTQI (Lesbian, Gay, Bisexual, Transgender, Questioning, Intersex) to be as inclusive as possible; however this term may not be inclusive of all sexual and gender minority individuals and we note that intersex are not traditionally included as an LGBT population [21]. As such, throughout this article we use the term sexual and gender minority individuals (SGMs) since it is an umbrella term that encompasses LGBT populations, as well as those whose sexual orientation and/or gender identity varies and those who may not self-identify as LGBT such as Queer, Questioning, Two-Spirit, Asexual, and MSM [22].
Section snippets
Study population and survey
The study was deemed exempt (Category 2) by the institutional review board (Liberty IRB, DeLand, FL). The study was conducted at the H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL an NCI-designated comprehensive cancer center that serves the population of the state as well as surrounding states and other countries. A link for a 32-item web-based survey was distributed to 388 oncology health care providers by email. Health care providers included all Medical Doctors (MD),
Demographics
One hundred and eight healthcare providers completed the survey for a 28% response rate (Table 1). Nearly 53% of respondents were less than 44 years of age. The majority of respondents identified as non-Hispanic White/Caucasian (62.0%), heterosexual (82.4%), Christian (51.9%), Doctor of Medicine (MD) (64.8%), and graduated from professional school between 2000 and 2009 (47.2%). Nearly 57% of respondents stated that between 1–5% of their patients in the past year had identified themselves as
Discussion
This is one of the first studies to assess knowledge, attitudes, and practice behaviors of healthcare providers in an oncology setting. Overall, knowledge among providers in terms of SGM health was lacking. In half of the questions in the knowledge section less than 50% of respondents were able to identify the correct response. Only 28% said that they were well informed on the health needs of SGM patients. Most providers acknowledged that there needed to be more education on SGM health needs.
Conflict of interest
No competing financial interests exist. Dr. Lancaster’s current affiliation is the Vice President of Medical Affairs at Myriad Genetic Laboratories. When this research was conducted, Dr. Lancaster was a Senior Member at the H. Lee Moffitt Cancer Center & Research Institute.
Funding
This research was supported by the Scholarly Concentrations Program at USF Health, Morsani College of Medicine and supported in part by the Survey Methods Core Facility at the H. Lee Moffitt Cancer Center & Research Institute; an NCI designated Comprehensive Cancer Center (P30-CA076292).
Acknowledgements
The authors wish to thank Ivana Sehovic, MPH, (H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL) for editorial assistance.
References (41)
- et al.
Anal human papillomavirus infection and associated neoplastic lesions in men who have sex with men: a systematic review and meta-analysis
Lancet Oncol.
(2012) - et al.
The same but different: clinician-patient communication with gay and lesbian patients
Patient Educ. Couns.
(2003) - et al.
Oncologists’ and family physicians’ views on value for money of cancer and congestive heart failure care
Isr. J. Health Policy Res.
(2013) NIH FY 2016–2020 Strategic Plan to Advance Research on the Health and Well-being of Sexual and Gender Minorities
(2015)The national academies collection: reports funded by national institutes of health
- et al.
Cancer and the LGBT Community
(2015) - et al.
Transgender health disparities: comparing full cohort and nested matched-pair study designs in a Community Health Center
LGBT Health
(2014) - et al.
Introduction to the special section on Lesbian, Gay, Bisexual, and Transgender (LGBT) health disparities: where we are and where we’re going
Ann. Behav. Med.
(2014) - et al.
Understanding health-care needs of sexual and gender minority veterans: how targeted research and policy can improve health
LGBT Health
(2014) - et al.
Cancer and lesbian, gay, bisexual, transgender/transsexual, and queer/questioning (LGBTQ) populations
CA Cancer J. Clin.
(2015)