Overcoming Barriers to Cancer Screening in Diverse LGBTQ Populations

A lack of cancer screening data and knowledge of screening guidelines have been cited as significant barriers to cancer screening adherence in lesbian, gay, bisexual, transgender and queer (LGBTQ) populations, diverse or otherwise, according to the results of an integrated review published in Oncology Nursing Forum.¹

The literature review considered several studies that identified gender identity and expression, racial and ethnic identity, socioeconomic status, knowledge gaps between patients and providers, poor psychosocial reactions and emotional coping, and lower education as potential barriers to screening.

In particular, gender identity and expression, as well as sexual orientation, were identified as factors that may act as screening barriers, with those who identify as gender nonconforming as well as transgender or bisexual being less likely to undergo screening for breast, cervical, and colon cancer.^2-4

Moreover, racial and ethnic identity was found to influence a patient’s perception of provider discrimination, investigators reported.⁵ In particular, minority status was associated with lower adherence rates to cervical cancer screenings in lesbian, gay, bisexual, and transgender individuals.⁶ Additionally, in one study, black lesbian, bisexual, and queer patients had reported discriminatory behavior leading to negative experiences when undergoing screenings.

“Multiple barriers and facilitators to cancer screening among LGBTQ populations were identified and crossed many levels of influence; these included ways that heteronormativity influences patients’ adherence to cancer screening and providers’ treatment of LGBTQ populations,” the authors of the study wrote. “Determinants of health-seeking behavior included patients’ lack of knowledge regarding screening; federal, national, and individual discrimination; and absent cancer screening guidelines.”

It has been suggested that the binary nature of heteronormativity has led to systematic discrimination of those who do not confirm to traditional gender roles or fall within a strict gender binary. Investigators aimed to examine how heteronormativity and provider attitude can influence participation in cancer screenings within the LGBTQ community.

Investigators identified relevant articles for this analysis through CINAHL, PsycINFO, and PubMed. Included articles needed to contain data-based research from studies of cancer screening barriers and facilitators within LGBTQ populations. Literature from 2008 and onward were included due to changes in the legal landscape and increased acceptance of the LGBTQ community. The search yielded 150 potential publications, of which 78 were reviewed and 12 were selected.

Additional findings from the analysis indicated that lesbian and bisexual women with less education were less likely to adhere to cervical cancer screenings. Comparatively, lesbians who had a high school education or less were less likely to have knowledge of the connection between the human papillomavirus (HPV) and cancer vs those with a college education but no degree. Investigators also identified financial instability as a barrier to both breast and cervical cancer screenings within the LGBTQ population.

Moreover, a lack of knowledge with regard to cancer screening guidelines for LGBTQ individuals, both within the LGBTQ community and among providers, is believed to contribute to poor screening activity. Additional lack of knowledge has been identified in gay men and lesbians with regard to the transmission of HPV through female-to-female contact and its association with the development of squamous cell carcinoma. It is also believed that women who are open with their providers regarding their sexual orientation were not informed as to the risks of HPV transmission, indicating an intersecting challenge between a lack of knowledge and provider- and team-related barriers; however, the reason for this association remained unclear.

Transmasculine individuals, in particular, were affected by psychosocial and coping-related factors such as gender incongruence and psychological distress when presenting for a Papanicolaou (Pap) test to screen for cervical cancer.8 In the study, transmasculine patients presented with severe emotional distress when undergoing cervical cancer screenings due to the fact that the procedure concerns female anatomy that does not align with their gender. Moreover, those within this subgroup who believe that fewer benefits could be achieved by undergoing a cervical cancer screening, as well as the belief that they are less susceptible to the disease, are less inclined to undergo screening. Due to this, gender dysphoria, which is defined as the conflict between an individual’s assigned gender and their gender identity, as well as identity destabilization, which occurs when an individual’s identity is threatened, were noted as significant barriers regarding cervical cancer screenings in transgender individuals.⁹

“Healthcare providers and members of the healthcare team affect LGBTQ populations’ care delivery in many ways,” the authors of the study wrote. “Themes that arose on the provider/team level as barriers to screening were knowledge and communication, cultural competency, and teamwork. Lack of knowledge and poor communication skills in providers were strong barriers to screening in many of the reviewed studies.”

Providers who assumed that their patients’ sexual orientation or gender identification (SOGI) aligned with their assigned sex were found to not appropriately recommend cancer screenings. The reasons for this could be due to perceived discrimination, as well as a lack of patient comfort in disclosing this information.¹⁰ Transmasculine individuals who reported experiencing discrimination were 3.3 times less likely to undergo routine cervical cancer screenings. Moreover, transgender men were found to have lower rates of Pap smears, along with transgender women and colorectal cancer screenings, as well as gender nonconforming individuals and prostate cancer screenings.

“Perceived lack of cultural competency by the provider also limited lesbian, bisexual, and transgender populations’ comfort with obtaining the appropriate screening,” the authors of the study wrote. “Transgender male patients experienced the need to negotiate gender with their provider when presenting for cervical cancer screening; this existed in the form of teaching the provider about gender status because of inappropriate, excessive, or invasive questions about sexual practices or anatomical surgeries.”

Transgender patients who needed to negotiate for their own needs to avoid feeling dehumanized or deindividualized were found to form negative opinions of screenings, leading to less of a likelihood to undergo future screenings.

Providers who refrained from assuming the sexual identity of their patients and used open ended questions regarding their patient’s sexual orientation inspired more comfort to undergo cervical cancer screenings in lesbian and bisexual women. Additionally, providers were able to achieve increased comfort in Black lesbian, bisexual, and queer women by demonstrating knowledge of same-sex sexual health; being of a shared race, ethnicity, or socioeconomic status; or congruence of sexual orientation.

Gentle physical touch and communicating the possibility of discomfort was associated with more positive screening experiences and increased screening adherence in transgender men, as well as lesbians, bisexuals, and queer women. Providers who implemented active listening and modification of examination for the comfort of transgender patients resulted in higher rates of screening satisfaction and decreased reports of gender dysphoria.

References

1. Haviland KS, Swette S, Kelechi T, et al. Barriers and facilitators to cancer screening among LGBTQ individuals with cancer. Oncol Nurs Forum. 2020;47(1):44-55. doi:10.1188/20.ONF.44-55
2. Bazzi AR, Whorms DS, King DS, et al. Adherence to mammography screening guidelines among transgender persons and sexual minority women. Am J Public Health. 2015;105(11):2356-2358. doi:10.2105/AJPH.2015.302851
3. Johnson MJ, Mueller M, Eliason MJ, et al. Quantitative and mixed analyses to identify factors that affect cervical cancer screening uptake among lesbian and bisexual women and transgender men. J Clin Nurs. 2016;25(23-24):3628-3642. doi:10.1111/jocn.13414
4. Tabaac AR, Sutter ME, Wall CSJ, et al. Gender identity disparities in cancer screening behaviors. Am J Prev Med. 2018;54(3):385-393. doi:10.1016/j.amepre.2017.11.009
5. Agénor M, Bailey Z, Krieger N, et al. Exploring the cervical cancer screening experiences of black lesbian, bisexual, and queer women: the role of patient-provider Communication. Women Health. 2015;55(6):717-736. doi:10.1080/03630242.2015.1039182
6. Tracy JK, Lydecker AD, Ireland L. Barriers to cervical cancer screening among lesbians. J Womens Health (Larchmt). 2010;19(2):229-237. doi:10.1089/jwh.2009.1393
7. Polek C, Hardie T. Lesbian women and knowledge about human papillomavirus. Oncol Nurs Forum. 2010;37(3):E191-197. doi:10.1188/10.ONF.E191-E197.
8. Peitzmeier SM, Agénor M, Bernstein IM, et al. "It can promote an existential crisis": factors influencing Pap test acceptability and utilization among transmasculine individuals. Qual Health Res. 2017;27(14):2138-2149. doi:10.1177/1049732317725513
9. What is gender dysphoria? American Psychiatric Association. Reviewed November 2020. Accessed June 25, 2021. https://bit.ly/3vVWjOV
10. Blackwell CW, Eden C. Human papillomavirus and anorectal carcinoma knowledge in men who have sex with men. J Assoc Nurses AIDS Care. 2011;22(6):444-453. doi:10.1016/j.jana.2011.08.004