Addressing Sexual and Gender Minority Care in Oncology

Daniel C. McFarland, DO, and Charles Kamen, PhD, MPH, discuss the unique challenges that sexual and gender minority groups experience in cancer care.

In the evolving landscape of oncology, providing high-quality care requires more than just clinical expertise; it demands a deep understanding of the diverse identities and lived experiences of every patient. Daniel C. McFarland, DO, and Charles Kamen, PhD, MPH, delved into the critical gaps in cancer care for LGBTQ+ individuals.

With nearly 10% of the US population now identifying as a sexual or gender minority, the oncologic community faces a growing imperative to address long-standing disparities in screening, treatment, and survivorship. The pair discussed the systemic impact of "minority stress" on the practical nuances of discussing pronouns and gender-affirming care. They also explored how clinicians can move past assumptions to foster true cultural humility.

Kamen provided actionable strategies—such as the use of nonverbal intake forms and the inclusion of "chosen family" in decision-making—to ensure that the cancer care continuum is affirming, safe, and equitable for all.

McFarland is the director of the Psycho-Oncology Program at Wilmot Cancer Center in Rochester, New York, and a medical oncologist who specializes in head, neck, and lung cancer, in addition to being the psycho-oncology editorial advisory board member for the journal ONCOLOGY. Kamen is an associate professor in the Department of Surgery, Cancer Control at the University of Rochester School of Medicine & Dentistry (SMD) and holds joint appointments as an associate professor at the Center for Community Health and Prevention and the Department of Psychiatry (SMD) at the University of Rochester Medical Center.

McFarland: We have all this training around what cancer care is, but not necessarily around what it means to foster these relationships, or how sexual and gender minority issues can affect cancer care. Charles, how would you describe the issue for us?

Kamen: There was a review done several years ago looking across medical center education programs about the amount of time those curricula spent on sexual and gender minority issues. Across programs, it was a handful of hours; 2 to 4 hours in most cases, which is a very short amount of time to [discuss] a very big topic [like] sexual orientation and gender identity in medical care in general.

As of 2024, a Gallup poll showed that 9.4% of the US population identified as a sexual gender minority. There was that thumbnail estimate of 10% of the population. When I started this work back in 2014/2015, in the context of cancer, the real estimate was about 3.7% of the US population identifying as a sexual gender minority. That shows how much more awareness there is about these identities over the past decade, and how much more comfortable people are in disclosing that they are a sexual gender minority. That’s almost 10%, which is a significant percentage of the population.

You talked about the difficulty that oncologists confront with a topic like this. You are expected to be an expert, to walk into the room and give people answers, and it’s hard. Cultural humility is hard. To go into the room and say, “I don’t know anything about your experience as a transgender patient, teach me so that I can then treat you better.” That is a difficult position to get to, but if you can, then that’s patient-centered care.

If you look across the cancer care continuum, from prevention to end of life, you see disparities for sexual and gender minorities at every stage of that continuum. There is this long-standing issue and disparity in terms of smoking tobacco use in the LGBTQ or sexual and gender minority community, with much higher rates of smoking. There are issues with screening, with certain kinds of screening being less common among LGBTQ or sexual and gender minority [groups], especially like pap smears among transgender men, which are much less utilized for treatment.

We could have a long conversation about this. It’s hard to know the real incidence rates at the population level in terms of cancer for sexual and gender minorities, but the best population estimates that we have showed that there is a higher rate, especially in certain segments of sexual and gender minority [groups] like gay and bisexual men. Some estimates have up to 2 times higher rates of cancer. I’m sure a portion of that is due to HIV- and AIDS-related malignancies, but there’s also a part that’s undoubtedly due to these risk factors that I was just talking about. Then, into survivorship, when [patients] finish their cancer treatment, there just aren’t [enough] resources available for sexual and gender minorities that there are for heterosexual and cisgender [patients], and so you have a lot of unmet needs as you move out of your treatment into the rest of your life.

McFarland: From going through the literature and my experience, what we’re talking about is maybe a system where there are assumptions that are made about your partner, your husband, your wife, or whatever lifestyle issues that there might be. What I’ve read is that [patients] may or may not feel comfortable correcting the clinician on these issues. The other part of it is that it was alluding to just how difficult it is for patients, in general, to confront an enormous system of which they know very little about. Imagine trying to do that while you’re also dealing with other issues.

What I think is important to understand is where these issues come from. You have this overarching, systems-level [issue], and it's very esoteric; how do you wrap your mind around it entirely? Then, you have a person in front of you, and when you’re sitting in a clinic with a patient, these issues might come up, or you might pass over them without even realizing them. Any thoughts about that?

Kamen: Disclosure is hard. Like you’re saying, it's difficult to advocate for yourself as a patient when you’re confronting a scary diagnosis like cancer. To then also, as the patient, have the onus of disclosing a stigmatized identity, like a sexual or gender minority identity, is a lot to take on. There’s this idea of minority stress. That’s where we see disparities in sexual and gender minority people. It’s not because they are sexual and gender minorities. It’s because, like you’re saying, they’re confronted by this giant system that is prejudiced in ways. Going through that system, they’re disempowered, they’re disenfranchised from care, and that’s what leads to the poor health outcomes down the line.

What is important to remember is that even anticipation of prejudice and discrimination can cause minority stress. You can be the best-intended oncologist in the world who wants to do the best for your patient, but the gay, lesbian, or transgender patient walking through the door may already have anticipated that you would have a bias against them, and so they could still be experiencing significant stress because of that. I don’t know that you can disentangle those 2 components of the big system and its impact on the patient and your relationship as a provider in that clinical encounter with the patient. You have to think about the whole spectrum. You have to have a care system that acknowledges that sexual and gender minority [groups] exist and are valid. Then, in your clinical encounter, the patient hopefully feels safe enough to disclose that to you, and you can have a patient-centered conversation about treatment options that take that person’s identity into account.

McFarland: That’s a great point because in my role as a psychiatrist, I always hear patients say that someone said something that was hurtful, and it’s not the doctor. Sometimes, it can be, but it’s often folks that the patient may not even interact with on a regular basis. It’s daunting to think that our patients are suffering based on things that we, at least on a 1:1 basis, have limited control over. That’s why I landed on this idea about relationship-centered care and getting to know your patient.

When I think about talking about sexual orientation, for example, or even using pronouns, they may be things that I'm not exactly feeling comfortable talking about. Right when I'm meeting someone, it may take some rapport to say, “I’m wondering about using third person pronouns and what that means for you? How would you like to be referred to?” I feel that we struggle with that. Sometimes, [there are] all these ought’s that we ought to be doing. We want to be the best we can be, and we’re trying to figure that out, but we’re just human. How do we do that? How do we manage it? How do you manage that in a limited time, in a clinical encounter?

Kamen: That’s a lot of territory to cover. You might have time to get in-depth with how somebody experiences their gender or their sexual orientation. I’ve done a lot of qualitative work talking to LGBTQ or sexual and gender minority patients with cancer, and a lot of times they say things like, “I just want the best care that I can get. That’s the most important thing for me with this diagnosis: to make sure that the care that I’m getting is high-quality.” That said, even over the last year, there’s been even more of a movement toward whole-person cancer care. Thinking about the whole person means thinking about everything that’s around the tumor or the malignancy. I don’t think it’s bad to have that conversation or have that be part of the experience.

At this point, we have to acknowledge that [for] talking about things like sexual orientation, gender identity, and pronouns, the comfort and the safety of doing that depends on time and place, where you are in history, and where you are geographically. Thus, the even bigger system is beyond a cancer center hospital. What is the state-level policy about LGBTQ people? What is the federal policy about LGBTQ people? All of that’s going to impact the patient walking into the room to have a conversation with you, but if you’re in a place where the policies align from federal to the state to the hospital to the cancer clinic level that a patient can be safe to disclose, the best way to do it, and research study after research study has shown this, is to have a nonverbal questionnaire or intake form where [patients] can denote their sexual orientation or gender identity.

It doesn't have to be a big thing that takes up a lot of time in the clinical encounter. They are data collected routinely on every patient that walks through the door, and you, as the clinician, can then use that to better inform your conversation with the patient. Patients prefer it. It’s less awkward for everybody. Then, it becomes a part of the medical record in a way that’s hopefully beneficial. The caveat to that is needing stringent protections in place, especially based on time and geographic location, to make sure if the data are entered in a durable way into the medical record, it’s not used to expose people to more discrimination and minority stress. Provided that’s true, the best way to do it is just, nonverbally, ask the patient at an intake and then use that data like you use any data from the medical record to inform your care.

McFarland: Let’s switch sides; now you’re the clinician. What are you going to do with the information I give you?

Kamen: This is a bigger thing to think about in terms of how you’re training people to use information effectively. Let’s break it down into a case example for gender identity and for sexual orientation. For gender identity, somebody comes into your clinic, works on the intake form, and identifies as transgender while using they/them pronouns that become part of their medical record. Let’s say they’re admitted to inpatient, and they have a bracelet that has their pronouns on it, and it says they/them. Even that is an affirming experience for a patient going through care. Even if you never verbally talk about it, the fact that it’s there, it’s in their patient portal, and it’s on their admission bracelet is affirming.

What you, as an oncologist, could do with that information is say, “I see that you marked your gender identity as transgender. Many times, patients are curious about gender-affirming care when they’re going through cancer care. Are you using or considering anything like hormones? If so, let's discuss how that would work with the treatment options that we have available.” When we were talking before, Dan, you mentioned that it feels more clinically relevant to say, “Okay, there’s a clinical component to your gender identity if you’re seeking gender-affirming care that we should know about as clinicians to treat you for your cancer effectively.”

Sexual orientation is a little harder in some ways because it doesn’t have the direct through line of a cancer or a clinical care component. I would say there are 2 ways in which it can manifest in a clinical encounter. One, if they’ve brought someone with them, their sexual orientation can hopefully shortcut the awkwardness of not knowing who this person is in their relationship to the patient, because you’ll have a sense, “Okay, they marked they are a lesbian. They brought another woman with them who’s clearly not related to them.” I can now begin a conversation by saying, “Who have you brought with you to the appointment today?” That is how we should always ask who our patients’ support partners are but not be surprised if that person is their wife. Another way it comes up is if you’re counseling people about the [adverse] effects of treatment, and this comes up a lot for sexual [adverse] effects. For example, if you know someone is a gay man and you’re prescribing treatments for colorectal cancer, you can have a different discussion about anal sex and [adverse] effects for anal sex than you would if you suspected the person wasn’t engaging in that behavior. You should always enter those conversations thoughtfully and carefully, but it just gives you a little bit more information that you can use to start the discussion in a sensitive and affirming way, as opposed to being caught off guard and not being prepared to answer any questions about sex or relationships.

McFarland: Patients are looking to us for those answers. If we don’t know how to ask the right questions, we can’t even begin to give them the answers that they need because they often may not realize that the cancer treatment is going to affect this part of their life. Charles got to one of my key questions, which was about the way in which gender identity and sexual orientation are often clumped together. I see them as distinct issues, and that’s how people experience them. Frankly, the gender identity often seemed more clinically relevant to me only because if you were born female and transition to male, you then need biologically appropriate surveillance. Things like that make a lot of sense.

I want to read something that I read from a paper: within the sexual and gender minority population, there are greater psychosocial concerns and lower mental health quality of life. The reported concerns about getting help with treatment, which we’ve talked about, are higher perceived interference with the ability to seek care and issues with daily emotional and pain interference. Managing those [adverse] effects can be problematic. This summary brought up a couple of unique psychosocial concerns. I want to make sure that we hit those unique psychosocial concerns.

Kamen: When patients report having a good relationship with a provider, it’s usually because there’s been an interpersonal connection that’s happened with them and the provider. [It also] oftentimes [happens] with their support people, with their caregivers, or their loved ones or their spouses; those individuals feel connected. When I hear things come up for LGBTQ [patients] that are unique, it’s oftentimes around the acknowledgement and the visibility of their identities in care. Many times, [patients] say, “My partner came with me to the care appointment but was treated more as a friend rather than a part of the decision-making process. I couldn’t help but think if I, as a man, had a woman as a partner, would they have been incorporated differently than [how] my male partner was?” That absolutely comes up often for people.

Even in the qualitative work that I’ve done, people sometimes question whether the sidelining of their caregiver or loved one is because of heterosexism or homophobia, or whether it’s just the oncologist’s bedside manner. But the important thing with that is knowing this individual in front of you is a sexual or gender minority. You know they’re going to be more sensitive to those cues of rejection and be anticipating bias and discrimination, so that will hopefully cue you as a provider to make an extra effort to include their caregiver, their support people, or their chosen family in the medical discussion and decision-making process. The visibility of a person’s identity and their relationships with other people are unique experiences. In one of our qualitative studies, we had a transgender patient talking about how he went through male chest reconstruction. [He] had a bilateral mastectomy, and then the chest built back up. As a matter of routine, they biopsied the removed chest tissue for cancer and discovered that this person had breast or chest cancer. He talked about the experience of going through gender-affirming care, getting to this point of having had a male chest reconstruction, being ready to celebrate his new body, and suddenly [becoming a patient with cancer]. It was a very challenging experience for him because he’d never gotten to celebrate his new body. Instead, he became a patient with cancer and now has this whole other thing layered on top of all the stress he was already experiencing going through gender-affirming care.

Want to listen to the full discussion? View the podcast now: https://www.cancernetwork.com/view/why-sexual-and-gender-minority-care-is-an-oncologic-imperative

Reference

Jones JM. LGBTQ+ identification in U.S. rises to 9.3%. Gallup. February 20, 2025. Accessed December 22, 2025. https://tinyurl.com/48n8j8bd